Provider Demographics
NPI:1346495298
Name:METAMORPHOSIS SALT LAKE CITY, INC.
Entity Type:Organization
Organization Name:METAMORPHOSIS SALT LAKE CITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICE
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:801-261-5790
Mailing Address - Street 1:339 E 3900 S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1677
Mailing Address - Country:US
Mailing Address - Phone:801-261-5790
Mailing Address - Fax:
Practice Address - Street 1:339 E 3900 S
Practice Address - Street 2:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-1677
Practice Address - Country:US
Practice Address - Phone:801-261-5790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5863251-8913261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone