Provider Demographics
NPI:1811301542
Name:DOUBLE DECKER
Entity type:Organization
Organization Name:DOUBLE DECKER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-703-9840
Mailing Address - Street 1:120 WEST 1470 SOUTH UNIT 100
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-7302
Mailing Address - Country:US
Mailing Address - Phone:435-703-9840
Mailing Address - Fax:
Practice Address - Street 1:120 WEST 1470 SOUTH UNIT 100
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-7302
Practice Address - Country:US
Practice Address - Phone:435-703-9840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7769324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility