Provider Demographics
NPI:1629567722
Name:RUBICON TRANSFORMATION CENTER, LLC
Entity Type:Organization
Organization Name:RUBICON TRANSFORMATION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEMELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-712-9640
Mailing Address - Street 1:822 E MAIN ST STE G
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-2501
Mailing Address - Country:US
Mailing Address - Phone:801-898-4686
Mailing Address - Fax:801-931-2027
Practice Address - Street 1:822 E MAIN ST STE G101
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84029-2500
Practice Address - Country:US
Practice Address - Phone:801-898-4686
Practice Address - Fax:801-931-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty