Provider Demographics
NPI:1356772537
Name:THISTLE CREEK RANCH
Entity type:Organization
Organization Name:THISTLE CREEK RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-362-4900
Mailing Address - Street 1:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-0542
Mailing Address - Country:US
Mailing Address - Phone:801-873-3199
Mailing Address - Fax:801-873-3507
Practice Address - Street 1:14048 SOUTH HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660
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:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4381324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility