Provider Demographics
NPI:1528223195
Name:TELOS RESIDENTIAL TREATMENT LLC
Entity Type:Organization
Organization Name:TELOS RESIDENTIAL TREATMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:COATES
Authorized Official - Suffix:
Authorized Official - Credentials:1871101205
Authorized Official - Phone:801-426-8800
Mailing Address - Street 1:PO BOX 537
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-0537
Mailing Address - Country:US
Mailing Address - Phone:801-426-8800
Mailing Address - Fax:
Practice Address - Street 1:870 W CENTER ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-5202
Practice Address - Country:US
Practice Address - Phone:801-426-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12164320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness