Healthcare Provider Details

I. General information

NPI: 1659315877
Provider Name (Legal Business Name): SAN JUAN COUNTY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 W 100 N SUITE A
MONTICELLO UT
84535-1054
US

IV. Provider business mailing address

PO BOX 1054
MONTICELLO UT
84535-1054
US

V. Phone/Fax

Practice location:
  • Phone: 435-587-5054
  • Fax: 435-587-3004
Mailing address:
  • Phone: 435-587-5054
  • Fax: 435-587-3004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2005-HOSP-203
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number2011-HOSP-203
License Number StateUT

VIII. Authorized Official

Name: CLAYTON HOLT
Title or Position: CFO
Credential:
Phone: 435-587-1112