Provider Demographics
NPI:1114121100
Name:SAN JUAN COUNTY HOSPITAL
Entity Type:Organization
Organization Name:SAN JUAN COUNTY HOSPITAL
Other - Org Name:SAN JUAN HEALTH SERVICE DISTRICT
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:LYMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-587-2116
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:UT
Mailing Address - Zip Code:84535-0308
Mailing Address - Country:US
Mailing Address - Phone:435-587-2116
Mailing Address - Fax:435-587-2061
Practice Address - Street 1:380 WEST 100 NORTH
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535-0308
Practice Address - Country:US
Practice Address - Phone:435-587-2116
Practice Address - Fax:435-587-2061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-HOSP-203261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========019Medicaid
UT=========071Medicaid
UT46Z308Medicare Oscar/Certification
UT=========071Medicaid
UT=========019Medicaid