MEDICARE: CANYON CREEK HOME HEALTH CARE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	2006-HHA-75037	UT
2	251E00000X	Home Health Agency	2011-HHA-75037	UT
3	251E00000X	Home Health Agency	2013-HHA-75037	UT
4	251E00000X	Home Health Agency
5	251E00000X	Home Health Agency	2015-HHA-75037	UT

General Provider Information

NPI Number	:	1174577753
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANYON CREEK HOME HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	3443 S STATE ST STE 9
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84115-4914
Country	:	US
Telephone Number	:	801-251-1595
Fax Number	:	801-251-1599

Provider Business Practice Location Address
First Line	:	3443 S STATE ST STE 9
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84115-4914
Country	:	US
Telephone Number	:	801-251-1595
Fax Number	:	801-251-1599

Authorized Official
Title or Position	:	OWNER
Name	:	DANIEL COSBY
Credential	:	HFA
Telephone Number	:	801-251-1595

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	04/17/2019

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