MEDICARE: SKOUT SOURCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251E00000X	Home Health Agency
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy

General Provider Information

NPI Number	:	1043950561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKOUT SOURCE

Provider Business Mailing Address
First Line	:	6955 S UNION PARK CTR STE 200
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84047-6514
Country	:	US
Telephone Number	:	877-467-5688
Fax Number	:

Provider Business Practice Location Address
First Line	:	6955 S UNION PARK CTR STE 200
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84047-6514
Country	:	US
Telephone Number	:	877-467-5688
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JOHN PETERSON
Credential	:
Telephone Number	:	949-556-5377

Provider Enumeration Date	:	03/31/2022
Last Update Date	:	03/31/2022

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