Provider Demographics
NPI:1467162081
Name:HEART MOUNTAIN CARE LLC
Entity Type:Organization
Organization Name:HEART MOUNTAIN CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHAY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:BALES
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:307-219-8509
Mailing Address - Street 1:333 S JONES ST LOT 4
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-3103
Mailing Address - Country:US
Mailing Address - Phone:307-219-8509
Mailing Address - Fax:
Practice Address - Street 1:333 S JONES ST LOT 4
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-3103
Practice Address - Country:US
Practice Address - Phone:307-219-8509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child