Provider Demographics
NPI:1003959149
Name:LARRY LINDE INC
Entity Type:Organization
Organization Name:LARRY LINDE INC
Other - Org Name:HERITAGE YOUTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CORBIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LINDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-798-9077
Mailing Address - Street 1:PO BOX 117
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660
Mailing Address - Country:US
Mailing Address - Phone:801-798-9077
Mailing Address - Fax:801-798-8949
Practice Address - Street 1:31 EAST 1600 NORTH
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660
Practice Address - Country:US
Practice Address - Phone:801-798-9077
Practice Address - Fax:801-798-8949
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LARRY LINDE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11559322D00000X
UT13995322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT788007788301Medicaid