Provider Demographics
NPI:1609201144
Name:WILLOW CREEK HOSPICE OF UTAH, LLC
Entity Type:Organization
Organization Name:WILLOW CREEK HOSPICE OF UTAH, LLC
Other - Org Name:PINE MOUNTAIN HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:TRACE
Authorized Official - Middle Name:D
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:801-277-3298
Mailing Address - Street 1:5200 S HIGHLAND DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7057
Mailing Address - Country:US
Mailing Address - Phone:801-277-3298
Mailing Address - Fax:801-277-3598
Practice Address - Street 1:1244 N MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9838
Practice Address - Country:US
Practice Address - Phone:435-248-0771
Practice Address - Fax:435-248-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT272046420001Medicaid
UT461586Medicare Oscar/Certification