Provider Demographics
NPI:1306186234
Name:WHITE RIVER ACADEMY
Entity Type:Organization
Organization Name:WHITE RIVER ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:NIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-659-2368
Mailing Address - Street 1:275 W 100 S
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:UT
Mailing Address - Zip Code:84624-9238
Mailing Address - Country:US
Mailing Address - Phone:435-659-2368
Mailing Address - Fax:435-213-2810
Practice Address - Street 1:275 W 100 S
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:UT
Practice Address - Zip Code:84624-9238
Practice Address - Country:US
Practice Address - Phone:435-659-2368
Practice Address - Fax:435-213-2810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-01
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility