Provider Demographics
NPI:1356476873
Name:CROSS CREEK MANOR, LLC
Entity Type:Organization
Organization Name:CROSS CREEK MANOR, LLC
Other - Org Name:CROSS CREEK MANOR
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KARR
Authorized Official - Middle Name:
Authorized Official - Last Name:FARNSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-635-6003
Mailing Address - Street 1:50 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:LA VERKIN
Mailing Address - State:UT
Mailing Address - Zip Code:84745-5400
Mailing Address - Country:US
Mailing Address - Phone:435-635-2390
Mailing Address - Fax:435-635-2778
Practice Address - Street 1:150 N STATE ST
Practice Address - Street 2:
Practice Address - City:LA VERKIN
Practice Address - State:UT
Practice Address - Zip Code:84745-5503
Practice Address - Country:US
Practice Address - Phone:435-635-2390
Practice Address - Fax:435-635-2778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12143322D00000X
UT12145323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Not Answered323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility