Provider Demographics
NPI:1689674301
Name:UTAH STATE DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:UTAH STATE DEVELOPMENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-763-4091
Mailing Address - Street 1:895 N. 900 E.
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9199
Mailing Address - Country:US
Mailing Address - Phone:801-763-4000
Mailing Address - Fax:801-763-4073
Practice Address - Street 1:895 N. 900 E.
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-9199
Practice Address - Country:US
Practice Address - Phone:801-763-4000
Practice Address - Fax:801-763-4073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2004-NCF-95310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness