Provider Demographics
NPI:1669557864
Name:GOOD SHEPHERD HOMECARE AND HOSPICE OF EASTERN UTAH, INC.
Entity type:Organization
Organization Name:GOOD SHEPHERD HOMECARE AND HOSPICE OF EASTERN UTAH, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATJASICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-277-6474
Mailing Address - Street 1:3584 W 9000 S STE 300
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5711
Mailing Address - Country:US
Mailing Address - Phone:801-277-6474
Mailing Address - Fax:
Practice Address - Street 1:266 W 100 N
Practice Address - Street 2:STE 2
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2012
Practice Address - Country:US
Practice Address - Phone:801-277-6474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251G00000X
UT2006-HOSPICE-72883251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT461560Medicare ID - Type UnspecifiedVERNAL HOSPICE