Provider Demographics
NPI:1164542379
Name:KEY RESIDENTIAL SERVICES
Entity Type:Organization
Organization Name:KEY RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:EKONG
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:801-360-6357
Mailing Address - Street 1:3322 MONTE VERDE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3227
Mailing Address - Country:US
Mailing Address - Phone:801-360-6357
Mailing Address - Fax:801-434-4391
Practice Address - Street 1:1361 S 740 E
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-8083
Practice Address - Country:US
Practice Address - Phone:801-434-4389
Practice Address - Fax:801-434-4391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT=========004Medicaid