Provider Demographics
NPI:1639565260
Name:SALT CREEK ADDICTION RECOVERY SERVICES
Entity type:Organization
Organization Name:SALT CREEK ADDICTION RECOVERY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:CMCH
Authorized Official - Phone:435-262-0891
Mailing Address - Street 1:PO BOX 316
Mailing Address - Street 2:
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646
Mailing Address - Country:US
Mailing Address - Phone:435-262-0891
Mailing Address - Fax:
Practice Address - Street 1:21360 N 1450 E
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646
Practice Address - Country:US
Practice Address - Phone:435-262-0891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT15W918383245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========Medicaid