Healthcare Provider Details

I. General information

NPI: 1699374496
Provider Name (Legal Business Name): MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 E 900 S STE 101
PROVO UT
84606-6107
US

IV. Provider business mailing address

589 S STATE ST
PROVO UT
84606-5056
US

V. Phone/Fax

Practice location:
  • Phone: 801-429-2000
  • Fax: 801-429-2001
Mailing address:
  • Phone: 801-855-0093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ERIC JOHNSON
Title or Position: FINANCIAL DIRECTOR
Credential:
Phone: 801-855-0091