Provider Demographics
NPI:1477886059
Name:BLUE MOUNTAIN FAMILY CENTER
Entity Type:Organization
Organization Name:BLUE MOUNTAIN FAMILY CENTER
Other - Org Name:WILDERNESS QUEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING CONSULTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-951-2317
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:UT
Mailing Address - Zip Code:84535-0012
Mailing Address - Country:US
Mailing Address - Phone:435-587-2801
Mailing Address - Fax:801-296-1715
Practice Address - Street 1:580 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535
Practice Address - Country:US
Practice Address - Phone:435-587-2801
Practice Address - Fax:801-296-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility