Provider Demographics
NPI:1174694095
Name:UTAH STATE UNIVERSITY
Entity type:Organization
Organization Name:UTAH STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-797-5830
Mailing Address - Street 1:6802 OLD MAIN HILL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-6802
Mailing Address - Country:US
Mailing Address - Phone:435-797-2750
Mailing Address - Fax:435-797-4054
Practice Address - Street 1:6802 OLD MAIN HILL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-6802
Practice Address - Country:US
Practice Address - Phone:435-797-2750
Practice Address - Fax:435-797-4054
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UTAH STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-13
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========059Medicaid