Provider Demographics
NPI:1003809369
Name:EZRA HEALTHCARE
Entity type:Organization
Organization Name:EZRA HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-770-4094
Mailing Address - Street 1:1881 W TRAVERSE PARKWAY
Mailing Address - Street 2:SUITE E#112
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-6029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3125 W EXECUTIVE PKWY STE 320
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-5972
Practice Address - Country:US
Practice Address - Phone:801-225-0990
Practice Address - Fax:801-225-4067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2003-HHA-16212251E00000X
UT2005-HOSPICE-65159251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT461545Medicare ID - Type UnspecifiedHOSPICE
UT467200Medicare ID - Type UnspecifiedHOME HEALTH