Provider Demographics
NPI:1700902376
Name:MOUNTAIN WEST HEARING AND SPEECH
Entity Type:Organization
Organization Name:MOUNTAIN WEST HEARING AND SPEECH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:VAN WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-A
Authorized Official - Phone:801-268-6497
Mailing Address - Street 1:777 E 4500 S STE 110
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3056
Mailing Address - Country:US
Mailing Address - Phone:801-268-6497
Mailing Address - Fax:
Practice Address - Street 1:777 E 4500 S STE 110
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3056
Practice Address - Country:US
Practice Address - Phone:801-268-6497
Practice Address - Fax:801-268-1376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT104094-4101237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528609027002Medicaid
UT=========OtherMOLINA HEALTH CARE
UT=========OtherUNITED HEALTH CARE