Provider Demographics
NPI:1609015155
Name:TRIUMPH YOUTH RANCH
Entity Type:Organization
Organization Name:TRIUMPH YOUTH RANCH
Other - Org Name:KOLOB CANYON RTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAWNY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:435-890-9180
Mailing Address - Street 1:PO BOX 531
Mailing Address - Street 2:1338 EAST 600 SOUTH
Mailing Address - City:NEW HARMONY
Mailing Address - State:UT
Mailing Address - Zip Code:84757-0531
Mailing Address - Country:US
Mailing Address - Phone:435-865-1437
Mailing Address - Fax:435-865-1439
Practice Address - Street 1:1338 EAST 600 SOUTH
Practice Address - Street 2:
Practice Address - City:NEW HARMONY
Practice Address - State:UT
Practice Address - Zip Code:84757-0531
Practice Address - Country:US
Practice Address - Phone:435-865-1437
Practice Address - Fax:435-865-1439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14109322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children