Provider Demographics
NPI:1710329958
Name:MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:801-429-2000
Mailing Address - Street 1:750 N 200 W
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1677
Mailing Address - Country:US
Mailing Address - Phone:801-429-2000
Mailing Address - Fax:801-429-2002
Practice Address - Street 1:750 N 200 W
Practice Address - Street 2:SUITE 201
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1677
Practice Address - Country:US
Practice Address - Phone:801-429-2000
Practice Address - Fax:801-429-2002
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-29
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT461838Medicare Oscar/Certification