Provider Demographics
NPI:1437692241
Name:CIRQUE LODGE INC
Entity Type:Organization
Organization Name:CIRQUE LODGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-222-9200
Mailing Address - Street 1:RR 3 BOX A10
Mailing Address - Street 2:
Mailing Address - City:SUNDANCE
Mailing Address - State:UT
Mailing Address - Zip Code:84604-8901
Mailing Address - Country:US
Mailing Address - Phone:801-222-9200
Mailing Address - Fax:801-222-0112
Practice Address - Street 1:3114 E IDA'S ROAD
Practice Address - Street 2:
Practice Address - City:SUNDANCE
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-222-9200
Practice Address - Fax:801-222-0112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT28275324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility