Provider Demographics
NPI:1750523338
Name:SALT LAKE INFECTIOUS DISEASE, LLC
Entity type:Organization
Organization Name:SALT LAKE INFECTIOUS DISEASE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MEZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-328-1260
Mailing Address - Street 1:1060 E 100 S
Mailing Address - Street 2:SUITE L10
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1501
Mailing Address - Country:US
Mailing Address - Phone:801-328-1260
Mailing Address - Fax:
Practice Address - Street 1:1060 E 100 S
Practice Address - Street 2:SUITE L10
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1501
Practice Address - Country:US
Practice Address - Phone:801-328-1260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty