Provider Demographics
NPI:1407112667
Name:YOUTH TRACK INC
Entity Type:Organization
Organization Name:YOUTH TRACK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:YOUTH COUNSLER
Authorized Official - Prefix:
Authorized Official - First Name:RHA'GENE
Authorized Official - Middle Name:DONTAE
Authorized Official - Last Name:BEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-317-3229
Mailing Address - Street 1:1034 ALAN PEAK CIR.
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404
Mailing Address - Country:US
Mailing Address - Phone:143-572-3179
Mailing Address - Fax:
Practice Address - Street 1:862 S
Practice Address - Street 2:SUITE 4
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302
Practice Address - Country:US
Practice Address - Phone:143-572-3179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT253JOOOOOX322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTHT006457001Medicaid