Provider Demographics
NPI:1164794434
Name:DE NOVO SERVICES LLC
Entity Type:Organization
Organization Name:DE NOVO SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-263-1056
Mailing Address - Street 1:339 E 3900 S
Mailing Address - Street 2:SUITE 155
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1677
Mailing Address - Country:US
Mailing Address - Phone:801-263-1056
Mailing Address - Fax:801-261-3701
Practice Address - Street 1:339 E 3900 S
Practice Address - Street 2:SUITE 155
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-1677
Practice Address - Country:US
Practice Address - Phone:801-263-1056
Practice Address - Fax:801-261-3701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)