Provider Demographics
NPI:1073046728
Name:COPPER SAGE RECOVERY CENTER
Entity Type:Organization
Organization Name:COPPER SAGE RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOLSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-455-4167
Mailing Address - Street 1:14014 S 2200 W
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-5325
Mailing Address - Country:US
Mailing Address - Phone:801-455-4167
Mailing Address - Fax:
Practice Address - Street 1:14014 S 2200 W
Practice Address - Street 2:
Practice Address - City:BLUFFDALE
Practice Address - State:UT
Practice Address - Zip Code:84065-5325
Practice Address - Country:US
Practice Address - Phone:801-455-4167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT50624324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility