Provider Demographics
NPI:1548823693
Name:OQUIRRH MOUNTAIN HEARING
Entity type:Organization
Organization Name:OQUIRRH MOUNTAIN HEARING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BC-HIS
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:LITTLEDIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-633-5196
Mailing Address - Street 1:506 N COOLEY ST
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-9359
Mailing Address - Country:US
Mailing Address - Phone:801-633-5196
Mailing Address - Fax:385-202-0542
Practice Address - Street 1:134 W 1180 N STE 5
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1483
Practice Address - Country:US
Practice Address - Phone:435-248-2842
Practice Address - Fax:385-202-0542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10297571-4602OtherBC-HIS- LICENSE NUMBER