Provider Demographics
NPI:1942251459
Name:SAN JUAN COUNTY HOSPITAL
Entity Type:Organization
Organization Name:SAN JUAN COUNTY HOSPITAL
Other - Org Name:SAN JUAN HEALTH SERVICES DISTRICT
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:H
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-587-2116
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:380 W 100 N
Mailing Address - City:MONTICELLO
Mailing Address - State:UT
Mailing Address - Zip Code:84535-0308
Mailing Address - Country:US
Mailing Address - Phone:435-587-2116
Mailing Address - Fax:435-587-2061
Practice Address - Street 1:380 WEST 100 NORTH
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535-0308
Practice Address - Country:US
Practice Address - Phone:435-587-2116
Practice Address - Fax:435-587-2061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2015-ALI-203208D00000X
UT2006-HOSP-203275N00000X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No275N00000XHospital UnitsMedicare Defined Swing Bed UnitGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========071Medicaid
UT=========019Medicaid
UT=========071Medicaid
UT461308Medicare Oscar/Certification
UTU000006105Medicare UPIN