MEDICARE: PEAK MEDICAL OF UTAH, 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	314000000X	Skilled Nursing Facility	2014NCF97	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	31118670601001	OTHER	UT	BLUE CROSS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366497794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEAK MEDICAL OF UTAH, LLC

Provider Business Mailing Address
First Line	:	101 SUN AVE NE
Second Line	:	COMPLIANCE DEPARTMENT
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4373
Country	:	US
Telephone Number	:	505-468-5604
Fax Number	:	505-468-4681

Provider Business Practice Location Address
First Line	:	400 E 5350 S
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84405-6931
Country	:	US
Telephone Number	:	801-479-9855
Fax Number	:	801-479-6219

Authorized Official
Title or Position	:	PRESIDENT DIRECTOR
Name	:	STEVE ROTHWELL
Credential	:
Telephone Number	:	505-821-3355

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	01/15/2016

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