Provider Demographics
NPI:1962492504
Name:LIFESKILLS VOCATIONAL CENTER
Entity Type:Organization
Organization Name:LIFESKILLS VOCATIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR CEO
Authorized Official - Phone:801-554-6992
Mailing Address - Street 1:15173 ROSE CANYON RD
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84065-4482
Mailing Address - Country:US
Mailing Address - Phone:801-554-6992
Mailing Address - Fax:801-977-3751
Practice Address - Street 1:1656 W 1500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104
Practice Address - Country:US
Practice Address - Phone:801-977-3732
Practice Address - Fax:801-977-3751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT19967974251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT=========CMedicaid