Healthcare Provider Details

I. General information

NPI: 1114152527
Provider Name (Legal Business Name): BLUE MOUNTAIN HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2009
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 S 200 W SUITE A
BLANDING UT
84511
US

IV. Provider business mailing address

802 S 200 W SUITE A
BLANDING UT
84511
US

V. Phone/Fax

Practice location:
  • Phone: 435-678-3993
  • Fax: 435-678-3992
Mailing address:
  • Phone: 435-678-3993
  • Fax: 435-678-3992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number2012-ESRD-90350
License Number StateUT

VIII. Authorized Official

Name: JEREMY LYMAN
Title or Position: CEO
Credential: MBA
Phone: 435-678-3993