Provider Demographics
NPI:1366863185
Name:PINE RIDGE BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:PINE RIDGE BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHENEY
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:435-469-0342
Mailing Address - Street 1:10380 EAST 22000 NORTH
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:UT
Mailing Address - Zip Code:84629
Mailing Address - Country:US
Mailing Address - Phone:435-469-0342
Mailing Address - Fax:
Practice Address - Street 1:10380 EAST 22000 NORTH
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:UT
Practice Address - Zip Code:84629
Practice Address - Country:US
Practice Address - Phone:435-469-0342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT21289320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness