Provider Demographics
NPI:1639492556
Name:PINE MOUNTAIN HOME HEALTH, LLC
Entity Type:Organization
Organization Name:PINE MOUNTAIN HOME HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:MR
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 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 1:5200 HIGHLAND DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-7057
Practice Address - Country:US
Practice Address - Phone:801-277-3298
Practice Address - Fax:801-277-3598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-05
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT467318Medicare Oscar/Certification