Basic Information
| Provider Information | |||||||||
| NPI: | 1285380394 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOAB VALLEY HEALTHCARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 WILLIAMS WAY | ||||||||
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| City: | MOAB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845322185 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 382 W CARE CAMPUS DRIVE | ||||||||
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| City: | MOAB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357193500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2022 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | WOJCIESZEK | ||||||||
| AuthorizedOfficialFirstName: | ZACH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4357193558 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOAB VALLEY HEALTHCARE, INC. | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.