Provider Demographics
NPI:1114446168
Name:CANCER SURVIVOR HEALTH NETWORK, L.L.C.
Entity Type:Organization
Organization Name:CANCER SURVIVOR HEALTH NETWORK, L.L.C.
Other - Org Name:SURVIVOR HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-754-6051
Mailing Address - Street 1:1338 S FOOTHILL DR # 333
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2321
Mailing Address - Country:US
Mailing Address - Phone:801-754-6051
Mailing Address - Fax:801-210-0476
Practice Address - Street 1:2486 EAST EMERSON AVENUE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108
Practice Address - Country:US
Practice Address - Phone:801-754-6051
Practice Address - Fax:801-210-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-11
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical InformaticsGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncologyGroup - Multi-Specialty
No364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncologyGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1164852224Medicaid