Provider Demographics
NPI:1689986457
Name:EXTENDED FAMILY BOYS, INC.
Entity Type:Organization
Organization Name:EXTENDED FAMILY BOYS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEDERHOLD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-794-0318
Mailing Address - Street 1:704 N STATE ROAD 51
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1385
Mailing Address - Country:US
Mailing Address - Phone:801-794-0318
Mailing Address - Fax:801-794-9514
Practice Address - Street 1:704 N STATE ROAD 51
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1385
Practice Address - Country:US
Practice Address - Phone:801-794-0318
Practice Address - Fax:801-794-9514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children