Provider Demographics
NPI:1659845352
Name:SUNDANCE CANYON EAST
Entity Type:Organization
Organization Name:SUNDANCE CANYON EAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-678-2425
Mailing Address - Street 1:11457 S 700 W
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9426
Mailing Address - Country:US
Mailing Address - Phone:866-678-2425
Mailing Address - Fax:
Practice Address - Street 1:11457 S 700 W
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9426
Practice Address - Country:US
Practice Address - Phone:866-678-2425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNDANCE CANYON EAST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTHLT-000051-2018OtherBUSINESS LICENSE