Provider Demographics
NPI:1336218924
Name:DUNGARVIN UTAH LLC
Entity Type:Organization
Organization Name:DUNGARVIN UTAH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-699-0206
Mailing Address - Street 1:1444 NORTHLAND DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1032
Mailing Address - Country:US
Mailing Address - Phone:651-699-0206
Mailing Address - Fax:651-699-0799
Practice Address - Street 1:4001 S 700 E
Practice Address - Street 2:SUITE 548
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-264-6633
Practice Address - Fax:801-264-6601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DUNGARVIN GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-07
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========Medicaid