Provider Demographics
NPI:1942600846
Name:RENASSAINCE RANCH OUTPATIENT
Entity Type:Organization
Organization Name:RENASSAINCE RANCH OUTPATIENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:REICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:801-450-7893
Mailing Address - Street 1:9160 S 300 W
Mailing Address - Street 2:13
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2655
Mailing Address - Country:US
Mailing Address - Phone:801-450-7893
Mailing Address - Fax:
Practice Address - Street 1:9160 S 300 W
Practice Address - Street 2:13
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2655
Practice Address - Country:US
Practice Address - Phone:801-450-7893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-27
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4625324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility