Provider Demographics
NPI:1033118674
Name:RHA COMMUNITY SERVICES OF UTAH
Entity Type:Organization
Organization Name:RHA COMMUNITY SERVICES OF UTAH
Other - Org Name:NORTH SIDE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CONOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-292-6797
Mailing Address - Street 1:PO BOX 1233
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-1233
Mailing Address - Country:US
Mailing Address - Phone:801-292-6797
Mailing Address - Fax:801-295-3660
Practice Address - Street 1:340 N 100 W
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6054
Practice Address - Country:US
Practice Address - Phone:801-292-6797
Practice Address - Fax:801-295-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-SHCF-344315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========034Medicaid