Provider Demographics
NPI:1578917787
Name:DEER HOLLOW OUTPATIENT SERVICES, LLC
Entity Type:Organization
Organization Name:DEER HOLLOW OUTPATIENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/DIRECTOR OF NURSING
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN
Authorized Official - Phone:801-810-1119
Mailing Address - Street 1:12608 S 125 W STE E
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8437
Mailing Address - Country:US
Mailing Address - Phone:801-810-1119
Mailing Address - Fax:801-203-9216
Practice Address - Street 1:12608 S 125 W STE E
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8437
Practice Address - Country:US
Practice Address - Phone:801-810-1119
Practice Address - Fax:801-203-9216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-14
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder