Healthcare Provider Details

I. General information

NPI: 1316304918
Provider Name (Legal Business Name): INTERMOUNTAIN HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W SPEECH AND HEARING
PROVO UT
84604-3380
US

IV. Provider business mailing address

1034 N 500 W
PROVO UT
84604-3380
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7448
  • Fax:
Mailing address:
  • Phone: 801-357-7448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number90852634102
License Number StateUT

VIII. Authorized Official

Name: MS. ASHLEE SPARROW
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: M.S., CCC/SLP
Phone: 435-881-3660