Provider Demographics
NPI:1932646148
Name:CANYON RIVER RANCH
Entity Type:Organization
Organization Name:CANYON RIVER RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-695-1016
Mailing Address - Street 1:244 OGDEN CYN
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-0958
Mailing Address - Country:US
Mailing Address - Phone:801-695-1016
Mailing Address - Fax:
Practice Address - Street 1:244 OGDEN CYN
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-0958
Practice Address - Country:US
Practice Address - Phone:801-695-1016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT30655320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness