1306083159 NPI number — WILLOW CREEK HOSPICE OF UTAH, L.L.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306083159 NPI number — WILLOW CREEK HOSPICE OF UTAH, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLOW CREEK HOSPICE OF UTAH, L.L.C.
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:
6
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:
1306083159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5200 S HIGHLAND DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
HOLLADAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84117-7057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-277-3298
Provider Business Mailing Address Fax Number:
801-277-3598

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5200 S HIGHLAND DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
HOLLADAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84117-7057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-277-3298
Provider Business Practice Location Address Fax Number:
801-277-3598
Provider Enumeration Date:
01/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
OSBORNE
Authorized Official First Name:
TRACE
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
801-272-3298

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , 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)

  • Identifier: 272046420001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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