Provider Demographics
NPI:1952848509
Name:RENAISSANCE RANCH BLUFFDALE WOMEN'S PROGRAM
Entity Type:Organization
Organization Name:RENAISSANCE RANCH BLUFFDALE WOMEN'S PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-856-7836
Mailing Address - Street 1:2973 W 13800 S
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2356 THUNDERHEAD WAY
Practice Address - Street 2:
Practice Address - City:BLUFFDALE
Practice Address - State:UT
Practice Address - Zip Code:84065
Practice Address - Country:US
Practice Address - Phone:801-545-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AWAKENING BEHAVIORAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-20
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT36385324500000X
UT37525324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility