Provider Demographics
NPI:1013249713
Name:ELEMENTS WILDERNESS PROGRAM
Entity Type:Organization
Organization Name:ELEMENTS WILDERNESS PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CONSULTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:COVINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-466-3838
Mailing Address - Street 1:5807 FONTAINE BLEU DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-1819
Mailing Address - Country:US
Mailing Address - Phone:801-712-3372
Mailing Address - Fax:
Practice Address - Street 1:130 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:UT
Practice Address - Zip Code:84528
Practice Address - Country:US
Practice Address - Phone:801-712-3372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT15403322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children