Provider Demographics
NPI:1629326574
Name:OUR HOUSE OF PROVO
Entity Type:Organization
Organization Name:OUR HOUSE OF PROVO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPAULDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-655-5090
Mailing Address - Street 1:462 S 900 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-5234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:462 S 900 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-5234
Practice Address - Country:US
Practice Address - Phone:801-655-5090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2012-ALII-106519310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========003Medicaid