Basic Information
| Provider Information | |||||||||
| NPI: | 1669690749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | LEE | ||||||||
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| OtherLastName: | ZEPEDA | ||||||||
| OtherFirstName: | SARA | ||||||||
| OtherMiddleName: | LEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 418 W CENTER ST | ||||||||
| Address2: | #13 | ||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012983239 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2250 ROBINS DR | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840411140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017737060 | ||||||||
| FaxNumber: | 8017746100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.