Provider Demographics
NPI:1780900464
Name:CROSS CREEK MANOR
Entity type:Organization
Organization Name:CROSS CREEK MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPA
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-635-2390
Mailing Address - Street 1:50 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:LA VERKIN
Mailing Address - State:UT
Mailing Address - Zip Code:84745-5443
Mailing Address - Country:US
Mailing Address - Phone:435-635-2390
Mailing Address - Fax:435-635-2778
Practice Address - Street 1:50 S STATE ST
Practice Address - Street 2:
Practice Address - City:LA VERKIN
Practice Address - State:UT
Practice Address - Zip Code:84745-5443
Practice Address - Country:US
Practice Address - Phone:435-635-2390
Practice Address - Fax:435-635-2778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT322D00000X, 323P00000X, 3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility