Provider Demographics
NPI:1457882508
Name:MIBOSPI
Entity Type:Organization
Organization Name:MIBOSPI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:BYRON
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-675-1242
Mailing Address - Street 1:1490 E 5600 S
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4525
Mailing Address - Country:US
Mailing Address - Phone:801-675-1242
Mailing Address - Fax:
Practice Address - Street 1:1490 E 5600 S
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4525
Practice Address - Country:US
Practice Address - Phone:801-675-1242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health