1154739787 NPI number — MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC.

Table of content: (NPI 1154739787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154739787 NPI number — MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154739787
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
589 S STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84606-5056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-429-2000
Provider Business Mailing Address Fax Number:
18-429-2001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
133 S 500 E
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
VERNAL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84078-2728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-789-2024
Provider Business Practice Location Address Fax Number:
435-789-2034
Provider Enumeration Date:
07/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BAILEY
Authorized Official First Name:
TODD
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
801-429-2000

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  138432-9922 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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