MEDICARE: GOLDEN COMPASS

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1316517311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN COMPASS

Provider Business Mailing Address
First Line	:	2600 N MAIN ST STE 200
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-1510
Country	:	US
Telephone Number	:	435-774-6533
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 N MAIN ST
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-5740
Country	:	US
Telephone Number	:	435-774-6533
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. COLDEN GLENN
Credential	:
Telephone Number	:	435-774-6533

Provider Enumeration Date	:	06/30/2021
Last Update Date	:	06/30/2021

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Directions to “GOLDEN COMPASS ” Practice Location

Language	Start Address	Practice Location

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