Provider Demographics
NPI:1134594286
Name:MOUNTAIN BROOK OUTPATIENT
Entity type:Organization
Organization Name:MOUNTAIN BROOK OUTPATIENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BROOK
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-228-8470
Mailing Address - Street 1:PO BOX 361
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-0361
Mailing Address - Country:US
Mailing Address - Phone:801-873-3199
Mailing Address - Fax:801-873-3507
Practice Address - Street 1:14048 S. HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-0361
Practice Address - Country:US
Practice Address - Phone:801-873-3199
Practice Address - Fax:801-873-3507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder