Provider Demographics
NPI:1619228327
Name:ASHLEY VALLEY WILDERNESS INC
Entity Type:Organization
Organization Name:ASHLEY VALLEY WILDERNESS INC
Other - Org Name:MOUNTAIN HOMES YOUTH RANCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-781-2450
Mailing Address - Street 1:247 S VERNAL AVE
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-3233
Mailing Address - Country:US
Mailing Address - Phone:435-781-2450
Mailing Address - Fax:435-781-2442
Practice Address - Street 1:247 S VERNAL AVE
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-3233
Practice Address - Country:US
Practice Address - Phone:435-781-2450
Practice Address - Fax:435-781-2442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1514781251S00000X
UT19546251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health