Provider Demographics
NPI:1508265612
Name:COLD CREEK WELLNESS CENTER
Entity Type:Organization
Organization Name:COLD CREEK WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-205-9229
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-0640
Mailing Address - Country:US
Mailing Address - Phone:801-205-9229
Mailing Address - Fax:801-544-0200
Practice Address - Street 1:8155 S BRIGHTON LOOP RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:UT
Practice Address - Zip Code:84121-9779
Practice Address - Country:US
Practice Address - Phone:801-205-9229
Practice Address - Fax:801-544-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9362324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility