Provider Demographics
NPI:1093818593
Name:HILDALE HEALTH SERVICE CENTER INC
Entity Type:Organization
Organization Name:HILDALE HEALTH SERVICE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EZRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-874-2217
Mailing Address - Street 1:1065 N HILDALE ST
Mailing Address - Street 2:
Mailing Address - City:HILDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84784-0459
Mailing Address - Country:US
Mailing Address - Phone:435-874-2217
Mailing Address - Fax:435-874-7817
Practice Address - Street 1:1065 N HILDALE ST
Practice Address - Street 2:
Practice Address - City:HILDALE
Practice Address - State:UT
Practice Address - Zip Code:84784-0459
Practice Address - Country:US
Practice Address - Phone:435-874-2217
Practice Address - Fax:435-874-7817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT=========001Medicaid