Basic Information
| Provider Information | |||||||||
| NPI: | 1023121290 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOOELE COUNTY HEALTH DEPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840742141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358432310 | ||||||||
| FaxNumber: | 4358432304 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840742141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358432310 | ||||||||
| FaxNumber: | 4358432304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | AHLSTROM | ||||||||
| AuthorizedOfficialFirstName: | SHERRIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COMMUNITY HEALTH SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4358432310 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | UT | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 690870121007 | 05 | UT | MEDICAID | 998877663001 | 05 | UT | MEDICAID |