Provider Demographics
NPI:1871644690
Name:ARK OF LITTLE COTTONWOOD
Entity Type:Organization
Organization Name:ARK OF LITTLE COTTONWOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BOBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-733-0200
Mailing Address - Street 1:2919 GRANITE HOLLOW ST
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-4217
Mailing Address - Country:US
Mailing Address - Phone:801-733-0200
Mailing Address - Fax:
Practice Address - Street 1:2919 GRANITE HOLLOW ST
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84092-4217
Practice Address - Country:US
Practice Address - Phone:801-733-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1459814-0140324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility