Provider Demographics
NPI:1972935625
Name:INNERCHANGE OAKLEY, LLC
Entity Type:Organization
Organization Name:INNERCHANGE OAKLEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-282-4782
Mailing Address - Street 1:661 EAST TECHNOLOGY AVENUE
Mailing Address - Street 2:BUILDING B, SUITE 1100
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-6209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 WEST WEBER CANYON ROAD
Practice Address - Street 2:
Practice Address - City:OAKLEY
Practice Address - State:UT
Practice Address - Zip Code:84055-0357
Practice Address - Country:US
Practice Address - Phone:433-783-5010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOLACIUM HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility