Provider Demographics
NPI:1366497794
Name:PEAK MEDICAL OF UTAH, LLC
Entity type:Organization
Organization Name:PEAK MEDICAL OF UTAH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTHWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-821-3355
Mailing Address - Street 1:101 SUN AVE NE
Mailing Address - Street 2:COMPLIANCE DEPARTMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4373
Mailing Address - Country:US
Mailing Address - Phone:505-468-5604
Mailing Address - Fax:505-468-4681
Practice Address - Street 1:400 E 5350 S
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6931
Practice Address - Country:US
Practice Address - Phone:801-479-9855
Practice Address - Fax:801-479-6219
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEAK MEDICAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2014NCF97314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV001988010Medicaid
ID806433900Medicaid
UT31118670601001OtherBLUE CROSS
WY120790300Medicaid
UT=========001Medicaid
WY120790300Medicaid
WY120790300Medicaid