Provider Demographics
NPI:1811054182
Name:UTAH STATE UNIVERSITY
Entity type:Organization
Organization Name:UTAH STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DRAKE
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-797-8528
Mailing Address - Street 1:809 N 800 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3634
Mailing Address - Country:US
Mailing Address - Phone:435-797-8529
Mailing Address - Fax:435-797-8530
Practice Address - Street 1:809 N 800 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-3634
Practice Address - Country:US
Practice Address - Phone:435-797-8532
Practice Address - Fax:435-797-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0700020385H00000X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No385H00000XRespite Care FacilityRespite Care