Basic Information
| Provider Information | |||||||||
| NPI: | 1164527792 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRISTOL HOSPICE - UTAH, L.L.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 255 E 400 S | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841112846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013250146 | ||||||||
| FaxNumber: | 8015969001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1638 N WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844043763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019240867 | ||||||||
| FaxNumber: | 8017473864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | KIRTON | ||||||||
| AuthorizedOfficialFirstName: | HYRUM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8013250175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRISTOL HOSPICE, L.L.C. | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | UT | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 1164527792 | 05 | UT | MEDICAID |