Provider Demographics
NPI:1619191095
Name:SECOND NATURE WILDERNESS PROGRAM
Entity Type:Organization
Organization Name:SECOND NATURE WILDERNESS PROGRAM
Other - Org Name:SECOND NATURE UINTAS
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-766-6604
Mailing Address - Street 1:382 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84021-0318
Mailing Address - Country:US
Mailing Address - Phone:435-738-2040
Mailing Address - Fax:435-738-2046
Practice Address - Street 1:382 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84021-0318
Practice Address - Country:US
Practice Address - Phone:435-738-2040
Practice Address - Fax:435-738-2046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT18067322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11846OtherSTATE LICENSE NUMBER