Provider Demographics
NPI:1629513833
Name:TELOS
Entity Type:Organization
Organization Name:TELOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMONT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-426-8800
Mailing Address - Street 1:870 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-5202
Mailing Address - Country:US
Mailing Address - Phone:801-921-9726
Mailing Address - Fax:
Practice Address - Street 1:661 S 1200 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5817
Practice Address - Country:US
Practice Address - Phone:801-921-9726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-23
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5079969-3501320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness