Provider Demographics
NPI:1457638587
Name:BRYCE CANYON ACADEMY OF UTAH, LLC
Entity Type:Organization
Organization Name:BRYCE CANYON ACADEMY OF UTAH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL OF BOARD
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:MILNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-669-4884
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:PAROWAN
Mailing Address - State:UT
Mailing Address - Zip Code:84761-0967
Mailing Address - Country:US
Mailing Address - Phone:435-477-9167
Mailing Address - Fax:
Practice Address - Street 1:580 N MAIN
Practice Address - Street 2:
Practice Address - City:PAROWAN
Practice Address - State:UT
Practice Address - Zip Code:84761
Practice Address - Country:US
Practice Address - Phone:435-477-9167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17338322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children