Healthcare Provider Details

I. General information

NPI: 1043950561
Provider Name (Legal Business Name): SKOUT SOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6955 S UNION PARK CTR STE 200
COTTONWOOD HEIGHTS UT
84047-6514
US

IV. Provider business mailing address

6955 S UNION PARK CTR STE 200
COTTONWOOD HEIGHTS UT
84047-6514
US

V. Phone/Fax

Practice location:
  • Phone: 877-467-5688
  • Fax:
Mailing address:
  • Phone: 877-467-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN PETERSON
Title or Position: MANAGING MEMBER
Credential:
Phone: 949-556-5377