Provider Demographics
NPI:1609266642
Name:LEGACY TREATMENT CENTER LLC
Entity Type:Organization
Organization Name:LEGACY TREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FADDIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:435-836-2272
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:LOA
Mailing Address - State:UT
Mailing Address - Zip Code:84747-0400
Mailing Address - Country:US
Mailing Address - Phone:435-836-2272
Mailing Address - Fax:435-836-2274
Practice Address - Street 1:1764 WEST ASPEN LANE
Practice Address - Street 2:
Practice Address - City:LOA
Practice Address - State:UT
Practice Address - Zip Code:84747-0400
Practice Address - Country:US
Practice Address - Phone:435-836-2272
Practice Address - Fax:435-836-2274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11669324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility