Provider Demographics
NPI:1952792004
Name:UTAH ADVOCACY NETWORK
Entity Type:Organization
Organization Name:UTAH ADVOCACY NETWORK
Other - Org Name:SYRACUSE SUPPORTED LIVING (UAN-SSL)
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:ANDREASEN
Authorized Official - Suffix:
Authorized Official - Credentials:QIDP DIRECTOR
Authorized Official - Phone:801-643-2866
Mailing Address - Street 1:2075 SOUTH BLUFF ROAD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9214
Mailing Address - Country:US
Mailing Address - Phone:801-776-1380
Mailing Address - Fax:801-784-4900
Practice Address - Street 1:2075 SOUTH BLUFF ROAD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9214
Practice Address - Country:US
Practice Address - Phone:801-776-1380
Practice Address - Fax:801-784-4900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT189610-3102-20170122163W00000X
320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5107101201Medicaid
UTHT007851-001OtherUHIN-TRADING PARTNER NUMBER