Provider Demographics
NPI:1174577753
Name:CANYON CREEK HOME HEALTH CARE LLC
Entity type:Organization
Organization Name:CANYON CREEK HOME HEALTH CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COSBY
Authorized Official - Suffix:
Authorized Official - Credentials:HFA
Authorized Official - Phone:801-251-1595
Mailing Address - Street 1:3443 S STATE ST STE 9
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4914
Mailing Address - Country:US
Mailing Address - Phone:801-251-1595
Mailing Address - Fax:801-251-1599
Practice Address - Street 1:3443 S STATE ST STE 9
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-4914
Practice Address - Country:US
Practice Address - Phone:801-251-1595
Practice Address - Fax:801-251-1599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-HHA-75037251E00000X
UT2011-HHA-75037251E00000X
UT2013-HHA-75037251E00000X
251E00000X
UT2015-HHA-75037251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT467227Medicare Oscar/Certification