Provider Demographics
NPI:1083107320
Name:RED CIRCLE LODGE, INC
Entity Type:Organization
Organization Name:RED CIRCLE LODGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LCMHC
Authorized Official - Phone:435-229-9437
Mailing Address - Street 1:930 N MEMORIAL ST #1670
Mailing Address - Street 2:
Mailing Address - City:HILDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84784
Mailing Address - Country:US
Mailing Address - Phone:435-874-1467
Mailing Address - Fax:
Practice Address - Street 1:930 N MEMORIAL ST
Practice Address - Street 2:
Practice Address - City:HILDALE
Practice Address - State:UT
Practice Address - Zip Code:84784
Practice Address - Country:US
Practice Address - Phone:435-874-1467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children