NPIMap

Organization Active NPI

San Juan County Hospital

Doing business as San Juan Clinic

  • Rural Health Clinic/Center
  • Monticello, UT
National Provider Identifier
1659315877
Registry record updated Jul 17, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
2011-HOSP-203 Issued in UT
Legal business name
SAN JUAN COUNTY HOSPITAL
Doing business as
San Juan Clinic
Practice address
380 W 100 N
Suite a
Monticello, UT 84535-1054
Phone
(435) 587-5054
Fax
(435) 587-3004
NPI assigned
Jun 16, 2006
Last updated
Jul 17, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 17, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Clayton Holt
Title
Cfo
Phone
(435) 587-1112

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X 2005-HOSP-203 UT
Rural Health Clinic/Center 261QR1300X 2011-HOSP-203 UT Primary

Addresses

Primary practice location

380 W 100 N
Suite a
Monticello, UT 84535-1054

Mailing address

PO Box 1054
Monticello, UT 84535-1054
Phone (435) 587-5054

Other names 1

  • San Juan Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040301000938 UT Part B Supplier - Clinic/Group Practice 4486541851 Receives reassigned benefits from 28 practitioners
4 other NPIs on this enrollment
Practice locations: Monticello, UT; Spanish Valley, UT
O20101117001371 UT Part A Provider - Rural Health Clinic 4486541851 Practice locations: Monticello, UT

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1659315877. Details of each certification follow.

Rural health clinic certification: CCN 463993

Legal name
SAN JUAN COUNTY HOSPITAL
Doing business as
SAN JUAN CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 25, 2012
Last certification
Jun 29, 2022
Ownership / control type
Non-profit – church related
Organization structure
GovernmentNon-profit
Enrollment address
380 West 100 North
Suite a
Monticello, UT 84535-1054
Related CCNs
461308

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
46D0960484San Juan Clinic380 W 100 N, Monticello, UT 84535Certificate of waiverMay 10, 2027

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
San Juan County Hospital Organization, Monticello, UT Non-profit 5% Or Greater Direct Ownership Interest Nov 4, 2014 100%
Clayton Holt Individual Corporate OfficerCeo Feb 1, 2015
Corporate DirectorCeo Feb 1, 2015
W-2 Managing EmployeeCeo Feb 1, 2015
Operational/Managerial ControlCeo Feb 1, 2015
Farley Crofts Individual Corporate OfficerCfo Oct 19, 2015
W-2 Managing EmployeeCfo Oct 19, 2015
Operational/Managerial ControlCfo Oct 19, 2015

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
San Juan County HospitalMonticello, UT, CCN 461308 Hospital 5% Or Greater Direct Ownership Interest (100%) Nov 4, 2014
San Juan County HospitalMonticello, UT, CCN 46Z308 Hospital 5% Or Greater Direct Ownership Interest (100%) Nov 4, 2014
San Juan Clinic BlandingBlanding, UT, CCN 463989 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Mar 1, 1999
Spanish Valley ClinicSpanish Valley, UT, CCN 463996 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Mar 1, 1999

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 4

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 28

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 28

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150416000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1721174400000",
    "number": "1659315877",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1054",
            "city": "MONTICELLO",
            "state": "UT",
            "postal_code": "845351054",
            "telephone_number": "435-587-5054",
            "fax_number": "435-587-3004"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "380 W 100 N",
            "address_2": "SUITE A",
            "city": "MONTICELLO",
            "state": "UT",
            "postal_code": "845351054",
            "telephone_number": "435-587-5054",
            "fax_number": "435-587-3004"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAN JUAN COUNTY HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-16",
        "last_updated": "2024-07-17",
        "certification_date": "2024-07-17",
        "status": "A",
        "authorized_official_last_name": "HOLT",
        "authorized_official_first_name": "CLAYTON",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "435-587-1112"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "UT",
            "license": "2005-HOSP-203",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "UT",
            "license": "2011-HOSP-203",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "San Juan Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Monticello, UT

Sources for this page

Verify at the official NPI Registry.