NPIMap

Organization Active NPI

Mountainlands Community Health Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Provo, UT
National Provider Identifier
1710329958
Registry record updated Mar 27, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC.
Practice address
750 N 200 W
Suite 201
Provo, UT 84601-1677
Phone
(801) 429-2000
Fax
(801) 429-2002
NPI assigned
Jul 29, 2013
Organization subpart
Yes
Parent organization
MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 27, 2025

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

Authorized official

Name
Mr. Todd Bailey, CMPE
Title
Executive Director
Phone
(801) 429-2000

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
PharmacistGroup: 193200000X MULTI-SPECIALTY GROUP 183500000X
Pharmacy TechnicianGroup: 193200000X MULTI-SPECIALTY GROUP 183700000X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

750 N 200 W
Suite 201
Provo, UT 84601-1677

Mailing address

750 N 200 W
Suite 201
Provo, UT 84601-1677
Phone (801) 429-2000

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140130002009 UT Part A Provider - Federally Qualified Health Center (FQHC) 6305872201 Practice locations: Provo, UT

Federally qualified health center certification: CCN 461838

Legal name
MOUNTAINLANDS COMMUNITY HEALTH CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 28, 2013
Last certification
Oct 28, 2013
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 19, 1992 in UT
Enrollment address
750 North 200 West
Provo, UT 84601

Other NPIs with the same Medicare PAC ID 4

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

National Provider Directory

National Provider Directory
Tax ID family
Mountainlands Family Pharmacy12 organizations share this tax ID, including this one
Part of
Mountainlands Family Pharmacy

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

Locations

750 N Freedom Blvd
Ste 201
Provo, UT 84601
Phone (801) 429-2000

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Lance Merrell Individual Corporate Director Jul 20, 2021
Logan Gillette Individual Corporate Director Aug 17, 2021
Kimberly Gonzalez Individual Corporate Director Sep 21, 2021
Adriana Chaua Individual Corporate Director Jun 19, 2018
Daniel Tventen Individual Corporate Director Jan 4, 2022
Monica Villarreal Individual Corporate Director May 19, 2020
Kirk Benge Individual Corporate Director Mar 16, 2021
Eric Edwards Individual Corporate Director Jan 19, 2021
Ralph Clegg Individual Corporate Director Nov 16, 2021
Charles Stubbs Individual Corporate Director May 19, 2020
Eric Johnson Individual Corporate OfficerFinancial Director May 19, 2010
W-2 Managing EmployeeFinancial Director Jan 1, 2010
Todd Bailey Individual Corporate Director Dec 15, 2009
W-2 Managing Employee Dec 15, 2009

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

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

{
    "created_epoch": "1375056000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1743033600000",
    "number": "1710329958",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "750 N 200 W",
            "address_2": "SUITE 201",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846011677",
            "telephone_number": "801-429-2000",
            "fax_number": "801-429-2002"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "750 N 200 W",
            "address_2": "SUITE 201",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846011677",
            "telephone_number": "801-429-2000",
            "fax_number": "801-429-2002"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MOUNTAINLANDS COMMUNITY HEALTH CENTER, INC.",
        "enumeration_date": "2013-07-29",
        "last_updated": "2025-03-27",
        "certification_date": "2025-03-27",
        "status": "A",
        "authorized_official_last_name": "BAILEY",
        "authorized_official_first_name": "TODD",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "801-429-2000",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CMPE"
    },
    "taxonomies": [
        {
            "code": "183500000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pharmacist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "183700000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pharmacy Technician",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Provo, UT

Sources for this page

Verify at the official NPI Registry.