MEDICARE: SECOND NATURE ENTRADA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center	12776	UT

General Provider Information

NPI Number	:	1063692804
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SECOND NATURE ENTRADA LLC

Provider Business Mailing Address
First Line	:	2711 SANTA CLARA DR
Second Line	:
City	:	SANTA CLARA
State	:	UT
Zip	:	84765-5466
Country	:	US
Telephone Number	:	435-674-9310
Fax Number	:	435-674-9309

Provider Business Practice Location Address
First Line	:	2711 SANTA CLARA DR
Second Line	:	SUITE 200
City	:	SANTA CLARA
State	:	UT
Zip	:	84765-5466
Country	:	US
Telephone Number	:	435-674-9310
Fax Number	:	435-674-9309

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. RICK L HEIZER
Credential	:	MS
Telephone Number	:	435-674-9310

Provider Enumeration Date	:	11/09/2007
Last Update Date	:	11/09/2007

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