Provider Demographics
NPI:1093189839
Name:ST. GEORGE DETOX CENTER LLC
Entity Type:Organization
Organization Name:ST. GEORGE DETOX CENTER LLC
Other - Org Name:ST. GEORGE DETOX HOSPITAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARKSDALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-533-8714
Mailing Address - Street 1:120 W 1470 S BLDG B
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-6798
Mailing Address - Country:US
Mailing Address - Phone:435-272-0220
Mailing Address - Fax:801-676-9340
Practice Address - Street 1:120 W 1470 S BLDG B
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-6798
Practice Address - Country:US
Practice Address - Phone:435-272-0220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARBROVITAE ENTERPRISES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2014-HOSP-UT000586284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital