Provider Demographics
NPI:1881235992
Name:STAT-MD II
Entity type:Organization
Organization Name:STAT-MD II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KNEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-604-0160
Mailing Address - Street 1:7724 S 5600 W STE 102
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-5415
Mailing Address - Country:US
Mailing Address - Phone:801-432-8480
Mailing Address - Fax:435-604-0160
Practice Address - Street 1:7724 S 5600 W STE 102
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84081-5415
Practice Address - Country:US
Practice Address - Phone:801-432-8480
Practice Address - Fax:435-604-0160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care