Provider Demographics
NPI:1326148073
Name:PHYSICIAN HOME CARE OF UTAH,L.C.
Entity Type:Organization
Organization Name:PHYSICIAN HOME CARE OF UTAH,L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DIETLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-944-0095
Mailing Address - Street 1:PO BOX 712270
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-2270
Mailing Address - Country:US
Mailing Address - Phone:801-944-0095
Mailing Address - Fax:
Practice Address - Street 1:6886 HOLLOW MILL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-3322
Practice Address - Country:US
Practice Address - Phone:801-944-0095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-23
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT169963-1205207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT530429522033Medicaid
UT530429522033Medicaid