Healthcare Provider Details

I. General information

NPI: 1134976020
Provider Name (Legal Business Name): UTE MOUNTAIN UTE TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 RUSTLING WILLOW ST
TOWAOC CO
81334-5062
US

IV. Provider business mailing address

PO BOX 169
TOWAOC CO
81334-0169
US

V. Phone/Fax

Practice location:
  • Phone: 970-564-5446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: GERALD WHITED
Title or Position: DIRECTOR
Credential:
Phone: 970-564-5446