Provider Demographics
NPI:1689846289
Name:CANYONLANDS MEDICAL LC
Entity Type:Organization
Organization Name:CANYONLANDS MEDICAL LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:
Authorized Official - First Name:DAR
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-393-6333
Mailing Address - Street 1:PO BOX 150193
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84415-0193
Mailing Address - Country:US
Mailing Address - Phone:801-393-6333
Mailing Address - Fax:801-394-6333
Practice Address - Street 1:5790 HARRISON BLVD
Practice Address - Street 2:STE. 2
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4325
Practice Address - Country:US
Practice Address - Phone:801-393-6333
Practice Address - Fax:801-394-6333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5528522-1703332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5528522-1703OtherPHARMACY
UT4954590001OtherMEDICARE SUPPLIER