MEDICARE: MOUNTAIN DIVISION - CVH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0400X	Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1063346211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN DIVISION - CVH, LLC

Provider Business Mailing Address
First Line	:	1655 N 200 E STE 2
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-1944
Country	:	US
Telephone Number	:	435-713-9700
Fax Number	:

Provider Business Practice Location Address
First Line	:	1655 N 200 E STE 2
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-1944
Country	:	US
Telephone Number	:	435-713-9700
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	STACEY CRANDALL
Credential	:
Telephone Number	:	435-713-9700

Provider Enumeration Date	:	06/11/2026
Last Update Date	:	06/11/2026

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