Provider Demographics
NPI:1184981201
Name:INTERMOUNTAIN COMMUNITY SUPPORTS AND SERVICES, LLC
Entity type:Organization
Organization Name:INTERMOUNTAIN COMMUNITY SUPPORTS AND SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-512-4045
Mailing Address - Street 1:5104 HERITAGE COVE
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129
Mailing Address - Country:US
Mailing Address - Phone:435-512-4045
Mailing Address - Fax:801-966-3312
Practice Address - Street 1:5104 HERITAGE COVE
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129
Practice Address - Country:US
Practice Address - Phone:435-512-4045
Practice Address - Fax:801-966-3312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT253Z00000X
251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care