Provider Demographics
NPI:1790230860
Name:INTERMOUNTAIN HEALTHCARE
Entity Type:Organization
Organization Name:INTERMOUNTAIN HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:801-662-5318
Mailing Address - Street 1:100 N MARIO CAPECCHI DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-5318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT78229114901282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren