Provider Demographics
NPI:1881658110
Name:CENTRAL VALLEY MEDICAL CENTER
Entity Type:Organization
Organization Name:CENTRAL VALLEY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-623-3000
Mailing Address - Street 1:48 W 1500 N
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-8900
Mailing Address - Country:US
Mailing Address - Phone:435-623-3000
Mailing Address - Fax:435-623-3123
Practice Address - Street 1:48 W 1500 N
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-8900
Practice Address - Country:US
Practice Address - Phone:435-623-3000
Practice Address - Fax:435-623-3123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-HOSP-171282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000887008Medicaid
UT461304Medicare Oscar/Certification