{
"Npi": {
"NPI": "1932823481",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "MOUNTAINLANDS COMMUNITY HEALTH CENTER INC",
"ParentOrgTIN": null,
"OrgName": "MOUNTAINLANDS COMMUNITY HEALTH CENTER INC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "589 S STATE ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PROVO",
"MailingAddressStateName": "UT",
"MailingAddressPostalCode": "84606-5056",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "801-429-2000",
"MailingAddressFaxNumber": "801-429-2002",
"FirstLinePracticeLocationAddress": "1680 W HIGHWAY 40 STE 201",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "VERNAL",
"PracticeLocationAddressStateName": "UT",
"PracticeLocationAddressPostalCode": "84078-4142",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "435-545-5175",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "09/28/2022",
"LastUpdateDate": "03/27/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BAILEY",
"AuthorizedOfficialFirstName": "TODD",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "EXECUTIVE DIRECTOR",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "801-429-2000",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QF0400X",
"TaxonomyName": "Federally Qualified Health Center (FQHC)",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}