Provider Demographics
NPI:1659315877
Name:SAN JUAN COUNTY HOSPITAL
Entity type:Organization
Organization Name:SAN JUAN COUNTY HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-587-1112
Mailing Address - Street 1:PO BOX 1054
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:UT
Mailing Address - Zip Code:84535-1054
Mailing Address - Country:US
Mailing Address - Phone:435-587-5054
Mailing Address - Fax:435-587-3004
Practice Address - Street 1:380 W 100 N
Practice Address - Street 2:SUITE A
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535-1054
Practice Address - Country:US
Practice Address - Phone:435-587-5054
Practice Address - Fax:435-587-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-HOSP-203207Q00000X
UT2011-HOSP-203261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========117Medicaid
UT463993Medicare Oscar/Certification