Provider Demographics
NPI:1629189634
Name:COUNTY OF DUCHESNE
Entity Type:Organization
Organization Name:COUNTY OF DUCHESNE
Other - Org Name:UINTAH BASIN REHABILITATION AND SENIOR VILLA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:H
Authorized Official - Last Name:HALES
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:435-722-6164
Mailing Address - Street 1:265 N 300 W
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066
Mailing Address - Country:US
Mailing Address - Phone:435-725-2051
Mailing Address - Fax:
Practice Address - Street 1:265 N 300 W
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066
Practice Address - Country:US
Practice Address - Phone:435-725-2051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-NCF-50755314000000X
UT2014-NCF-50755314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT465084Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
UT=========001Medicaid