Provider Demographics
NPI:1336523695
Name:BLUE HILLS RESIDENTIAL TREATMENT
Entity Type:Organization
Organization Name:BLUE HILLS RESIDENTIAL TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERN
Authorized Official - Prefix:
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:COLBURN
Authorized Official - Suffix:
Authorized Official - Credentials:CMHCI
Authorized Official - Phone:435-445-5200
Mailing Address - Street 1:PO BOX 461
Mailing Address - Street 2:2860 EAST 19500 NORTH
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646-0461
Mailing Address - Country:US
Mailing Address - Phone:435-445-5200
Mailing Address - Fax:435-445-5201
Practice Address - Street 1:2860 EAST 19500 NORTH
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646-0461
Practice Address - Country:US
Practice Address - Phone:435-436-9029
Practice Address - Fax:435-445-5201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1235458555Medicaid