Provider Demographics
NPI:1770513236
Name:MOAB VALLEY HEALTHCARE, INC
Entity type:Organization
Organization Name:MOAB VALLEY HEALTHCARE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SADOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-719-3514
Mailing Address - Street 1:450 W WILLIAMS WAY
Mailing Address - Street 2:P.O.BOX 998
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-0998
Mailing Address - Country:US
Mailing Address - Phone:435-719-3501
Mailing Address - Fax:435-719-3509
Practice Address - Street 1:450 W WILLIAMS WAY
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2065
Practice Address - Country:US
Practice Address - Phone:435-719-3501
Practice Address - Fax:435-719-3509
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOAB VALLEY HEALTHCARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-03
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-HOSPICE-926251G00000X
UT282NC2000X
UT2005-HOSP-45117282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No251G00000XAgenciesHospice Care, Community Based
No282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT461518OtherHOSPICE MEDICARE
UT870391981011Medicaid
UT461302Medicare Oscar/Certification
UT461518Medicare ID - Type UnspecifiedGRAND COUNTY HOSPICE
UT46Z302Medicare PIN
UT461518OtherHOSPICE MEDICARE