=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174577753
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANYON CREEK HOME HEALTH CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 04/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3443 S STATE ST STE 9
-----------------------------------------------------
City | SOUTH SALT LAKE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84115-4914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-251-1595
-----------------------------------------------------
Fax | 801-251-1599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3443 S STATE ST STE 9
-----------------------------------------------------
City | SOUTH SALT LAKE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84115-4914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-251-1595
-----------------------------------------------------
Fax | 801-251-1599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL COSBY
-----------------------------------------------------
Credential | HFA
-----------------------------------------------------
Telephone | 801-251-1595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 2006-HHA-75037
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 2011-HHA-75037
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 2013-HHA-75037
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 2015-HHA-75037
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------