Healthcare Provider Details

I. General information

NPI: 1558513812
Provider Name (Legal Business Name): BLUE MOUNTAIN HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 S 200 WEST SUITE A
BLANDING UT
84511
US

IV. Provider business mailing address

802 S 200 WEST 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 Number2010-ESRD-90350
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code261QC0050X
TaxonomyCritical Access Hospital Clinic/Center
License Number2011-HOSP-96389
License Number StateUT

VIII. Authorized Official

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