MEDICARE: RHA COMMUNITY SERVICES OF UTAH

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	2004-SHCF-158	UT

General Provider Information

NPI Number	:	1396745378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RHA COMMUNITY SERVICES OF UTAH

Provider Business Mailing Address
First Line	:	642 UNIVERSITY ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-3213
Country	:	US
Telephone Number	:	801-582-2195
Fax Number	:	801-582-3901

Provider Business Practice Location Address
First Line	:	642 UNIVERSITY ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-3213
Country	:	US
Telephone Number	:	801-582-2195
Fax Number	:	801-582-3901

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JACKLYNN IVY HUGHES
Credential	:
Telephone Number	:	801-582-8097

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	08/22/2020

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