Healthcare Provider Details

I. General information

NPI: 1467811562
Provider Name (Legal Business Name): CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S 200 E
SALT LAKE CITY UT
84111-3835
US

IV. Provider business mailing address

HC 61 BOX 6104
IBAPAH UT
84034-6003
US

V. Phone/Fax

Practice location:
  • Phone: 801-359-2256
  • Fax: 801-364-4392
Mailing address:
  • Phone: 435-234-1138
  • Fax: 435-234-1162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number8547079-1704
License Number StateUT

VIII. Authorized Official

Name: LINDA THATCHER
Title or Position: BILLING
Credential:
Phone: 801-359-2256