Basic Information
| Provider Information | |||||||||
| NPI: | 1194212514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEDDLESTEN | ||||||||
| FirstName: | CALLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4444 S 700 E STE 203 | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841073075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012684887 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4444 S 700 E | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841073075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012684887 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2018 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | Other Service Providers | Specialist | 246Z00000X | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other |
No ID Information.