MEDICARE: RHA HEALTH SERVICE UT 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	2015SHCF-22	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	46D0977163	OTHER	UT	CLIA

General Provider Information

NPI Number	:	1629447370
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RHA HEALTH SERVICE UT LLC

Provider Business Mailing Address
First Line	:	642 S 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	:	650 S 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	:	DIRECTOR OF OPERATIONS
Name	:	MRS. CHRISTINE L CHRISTENSEN
Credential	:
Telephone Number	:	801-763-9299

Provider Enumeration Date	:	09/23/2015
Last Update Date	:	09/25/2015

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