Provider Demographics
NPI:1407088917
Name:WATERFALL CANYON ACADEMY, INC.
Entity Type:Organization
Organization Name:WATERFALL CANYON ACADEMY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-621-3901
Mailing Address - Street 1:3375 HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1228
Mailing Address - Country:US
Mailing Address - Phone:801-621-3901
Mailing Address - Fax:
Practice Address - Street 1:818 N 950 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-3866
Practice Address - Country:US
Practice Address - Phone:801-399-1402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT15034322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children