Provider Demographics
NPI:1629423280
Name:UTAH ADDICTION CENTERS
Entity Type:Organization
Organization Name:UTAH ADDICTION CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:QUENTIN
Authorized Official - Last Name:BOBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-634-8938
Mailing Address - Street 1:2590 E PRAIRIE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-6096
Mailing Address - Country:US
Mailing Address - Phone:801-766-2233
Mailing Address - Fax:
Practice Address - Street 1:2590 E PRAIRIE VIEW DR
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-6096
Practice Address - Country:US
Practice Address - Phone:801-766-2233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13999320800000X
UT21344324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility