Provider Demographics
NPI:1598118747
Name:THE BLOC OUTPATIENT, LLC
Entity Type:Organization
Organization Name:THE BLOC OUTPATIENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-669-3967
Mailing Address - Street 1:716 E 4500 S STE S260
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3611
Mailing Address - Country:US
Mailing Address - Phone:801-669-3967
Mailing Address - Fax:
Practice Address - Street 1:716 E 4500 S STE S260
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-3611
Practice Address - Country:US
Practice Address - Phone:801-669-3967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility