Provider Demographics
NPI:1467263004
Name:EOS SERENITY LODGE
Entity type:Organization
Organization Name:EOS SERENITY LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLESH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-304-3489
Mailing Address - Street 1:1445 E 5600 S
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1445 E 5600 S
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4537
Practice Address - Country:US
Practice Address - Phone:801-513-7174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility