Provider Demographics
NPI:1295740652
Name:FLAGLIFE, INC
Entity type:Organization
Organization Name:FLAGLIFE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:POULTON
Authorized Official - Suffix:
Authorized Official - Credentials:C, PED
Authorized Official - Phone:435-652-0100
Mailing Address - Street 1:362 W SAINT GEORGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3352
Mailing Address - Country:US
Mailing Address - Phone:435-652-0100
Mailing Address - Fax:435-652-0103
Practice Address - Street 1:362 W SAINT GEORGE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3352
Practice Address - Country:US
Practice Address - Phone:435-652-0100
Practice Address - Fax:435-652-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTDESERET MUTUAL BENEFOtherDMBA MANAGED CARE PLAN
UT=========001Medicaid
UT5199350001Medicare NSC