Provider Demographics
NPI:1710344585
Name:RENAISSANCE RANCH OUTPATIENT TREATMENT
Entity Type:Organization
Organization Name:RENAISSANCE RANCH OUTPATIENT TREATMENT
Other - Org Name:RENAISSANCE RANCH OUTPATIENT - OREM WOMEN
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:WACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-381-2928
Mailing Address - Street 1:591 W 800 N STE 202
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:591 W 800 N STE 202
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3762
Practice Address - Country:US
Practice Address - Phone:801-572-4325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RENAISSANCE RANCH OUTPATIENT TREATMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4625324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility