Provider Demographics
NPI:1609982107
Name:HOSPICE ALLIANCE OF SOUTHERN UTAH, INC.
Entity Type:Organization
Organization Name:HOSPICE ALLIANCE OF SOUTHERN UTAH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-753-0707
Mailing Address - Street 1:965 S 100 W STE 204
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6072
Mailing Address - Country:US
Mailing Address - Phone:435-753-0707
Mailing Address - Fax:435-755-8505
Practice Address - Street 1:965 E 700 S
Practice Address - Street 2:SUITE 201
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4082
Practice Address - Country:US
Practice Address - Phone:435-656-2889
Practice Address - Fax:435-656-2877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-HOSPICE-67900251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT461547Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER