Provider Demographics
NPI:1043260771
Name:TRINITY MISSION HEALTH & REHAB OF PROVO, LP
Entity type:Organization
Organization Name:TRINITY MISSION HEALTH & REHAB OF PROVO, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ULLERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7994
Mailing Address - Street 1:1053 W 1020 S
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-5656
Mailing Address - Country:US
Mailing Address - Phone:801-373-2630
Mailing Address - Fax:801-373-2660
Practice Address - Street 1:1053 W 1020 S
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-5656
Practice Address - Country:US
Practice Address - Phone:801-373-2630
Practice Address - Fax:801-373-2660
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT DOVE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-NCF-43314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT990177577005Medicaid
UT990177577005Medicaid