MEDICARE: TRANQUILITY PLACE OF UTAH 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	17016	UT

General Provider Information

NPI Number	:	1942502638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRANQUILITY PLACE OF UTAH LLC

Provider Business Mailing Address
First Line	:	160 E 800 S STE B
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-3827
Country	:	US
Telephone Number	:	801-924-9240
Fax Number	:	801-924-9241

Provider Business Practice Location Address
First Line	:	160 E 800 S STE B
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-3827
Country	:	US
Telephone Number	:	801-924-9240
Fax Number	:	801-924-9241

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MR. TONY TALIA'ULI
Credential	:	BA
Telephone Number	:	801-924-9240

Provider Enumeration Date	:	12/01/2010
Last Update Date	:	01/02/2020

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