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
State | License ID | Taxonomies |
---|---|---|
UT | 9362 | 324500000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |