Healthcare Provider Details

I. General information

NPI: 1639492556
Provider Name (Legal Business Name): PINE MOUNTAIN HOME HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 02/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 HIGHLAND DR SUITE 200
HOLLADAY UT
84117-7057
US

IV. Provider business mailing address

5200 HIGHLAND DR SUITE 200
HOLLADAY UT
84117-7057
US

V. Phone/Fax

Practice location:
  • Phone: 801-277-3298
  • Fax: 801-277-3598
Mailing address:
  • Phone: 801-277-3298
  • Fax: 801-277-3598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
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: MR. TRACE D. OSBORNE
Title or Position: ACCOUNTANT
Credential: CPA
Phone: 801-277-3298