Provider Demographics
NPI:1336144096
Name:CANYONLANDS MEDICAL LC
Entity Type:Organization
Organization Name:CANYONLANDS MEDICAL LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:EARLE
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-634-7625
Mailing Address - Street 1:285 W TABERNACLE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3385
Mailing Address - Country:US
Mailing Address - Phone:435-634-7625
Mailing Address - Fax:435-634-0716
Practice Address - Street 1:285 W TABERNACLE ST
Practice Address - Street 2:STE 101
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3385
Practice Address - Country:US
Practice Address - Phone:435-634-7625
Practice Address - Fax:435-634-0716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5528522-1703332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5528522-1703OtherPHARMACY NUMBER
UT4954590001Medicare ID - Type UnspecifiedPROVIDER NUMBER
UT5528522-1703OtherPHARMACY NUMBER