Healthcare Provider Details

I. General information

NPI: 1548643745
Provider Name (Legal Business Name): BEAUTIFUL MOUNTAIN BIRTH SUITES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 E 12300 S STE 2
DRAPER UT
84020-8276
US

IV. Provider business mailing address

826 E 12300 S STE 2
DRAPER UT
84020-8276
US

V. Phone/Fax

Practice location:
  • Phone: 801-252-6243
  • Fax: 801-892-0788
Mailing address:
  • Phone: 801-252-6243
  • Fax: 801-892-0788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ANGIE R BLACKETT
Title or Position: OWNER/EDUCATION DIRECTOR
Credential: CPM, LDEM
Phone: 801-252-6243