NPIMap

San Juan County Hospital

Organization Active NPI Rural Health Clinic/Center · Monticello, UT

NPI 1659315877 · NPPES record last updated Jul 17, 2024

Key facts

NPI
1659315877
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
License
2011-HOSP-203 (UT)
Legal business name
SAN JUAN COUNTY HOSPITAL
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
Organization subpart
No

Authorized official

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

Owners & managing parties with NPI records 4

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

Owned or controlled facilities with NPI records 4

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

Other NPIs on the same Medicare enrollment 4

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

Other NPIs with the same Medicare PAC ID 4

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

Member of 1

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

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

Facilities with the same owner 4

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

Practitioners 28

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 28

Laboratory certificates & supplier records

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

CLIA laboratory certificates

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

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in UT

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
Government · Non-profit
Enrollment address
380 West 100 North
Suite a
Monticello, UT 84535-1054
Related CCNs
461308

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 Officer
Ceo		 Feb 1, 2015
Corporate Director
Ceo		 Feb 1, 2015
W-2 Managing Employee
Ceo		 Feb 1, 2015
Operational/Managerial Control
Ceo		 Feb 1, 2015
Farley Crofts
Individual 		Corporate Officer
Cfo		 Oct 19, 2015
W-2 Managing Employee
Cfo		 Oct 19, 2015
Operational/Managerial Control
Cfo		 Oct 19, 2015

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

Medicare enrollment records

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

National Provider Directory

Locations

735 S 200 W
Ste 3
Blanding, UT 84511
Phone (435) 678-2254

5555 Old Airport Rd
Moab, UT 84532
Phone (435) 419-9210

Specialties & licenses

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

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

  • San Juan Clinic Doing business as

Other providers in Monticello, UT

All providers in Monticello, UT · Rural Health Clinic/Center in Utah

Sources for this page

Verify at the official NPI Registry.