Healthcare Provider Details

I. General information

NPI: 1578880415
Provider Name (Legal Business Name): BLUE MOUNTAIN HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 S 200 W
BLANDING UT
84511-3910
US

IV. Provider business mailing address

802 S 200 W
BLANDING UT
84511-3910
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 TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number2009-HOSP-90347
License Number StateUT

VIII. Authorized Official

Name: MR. LORIN C MACKAY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 435-678-3993