Provider Demographics
NPI:1689988933
Name:FAMMULL, INC.
Entity Type:Organization
Organization Name:FAMMULL, INC.
Other - Org Name:BRIGHTSTAR MOUNTAINSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMRA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:801-290-1290
Mailing Address - Street 1:5330 S 900 E
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7261
Mailing Address - Country:US
Mailing Address - Phone:801-290-1290
Mailing Address - Fax:801-290-1291
Practice Address - Street 1:5330 S 900 E
Practice Address - Street 2:SUITE 260
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-7261
Practice Address - Country:US
Practice Address - Phone:801-290-1290
Practice Address - Fax:801-290-1291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2010-HHA-96627251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health