Provider Demographics
NPI:1326418328
Name:DDMS OF UTAH NO.2
Entity Type:Organization
Organization Name:DDMS OF UTAH NO.2
Other - Org Name:NORTH SIDE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MISTI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:DO/ADMINISTRATOR
Authorized Official - Phone:801-763-9299
Mailing Address - Street 1:119 S PACIFIC DR
Mailing Address - Street 2:119
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2196
Mailing Address - Country:US
Mailing Address - Phone:801-763-9299
Mailing Address - Fax:801-763-1121
Practice Address - Street 1:340 N 100 W
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6054
Practice Address - Country:US
Practice Address - Phone:801-292-6797
Practice Address - Fax:801-295-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2015-SHCF-344320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2015-SHCF-344Medicaid