Provider Demographics
NPI:1326504523
Name:TEARACE ENT., LLC
Entity Type:Organization
Organization Name:TEARACE ENT., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SODERQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:435-691-0856
Mailing Address - Street 1:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:KANAB
Mailing Address - State:UT
Mailing Address - Zip Code:84741-0061
Mailing Address - Country:US
Mailing Address - Phone:928-643-6000
Mailing Address - Fax:928-643-6024
Practice Address - Street 1:1739 S HIGHWAY 89A
Practice Address - Street 2:
Practice Address - City:KANAB
Practice Address - State:UT
Practice Address - Zip Code:84741-3957
Practice Address - Country:US
Practice Address - Phone:928-643-6000
Practice Address - Fax:928-643-6024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder