MEDICARE: CREATIVE HEARTS OUTPATIENT CENTER, 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1962185280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE HEARTS OUTPATIENT CENTER, LLC

Provider Business Mailing Address
First Line	:	4048 RIVERDALE RD STE 1199
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84405-1518
Country	:	US
Telephone Number	:	775-292-3535
Fax Number	:	385-510-2008

Provider Business Practice Location Address
First Line	:	4048 RIVERDALE RD STE 1199
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84405-1518
Country	:	US
Telephone Number	:	775-292-3535
Fax Number	:	385-510-2008

Authorized Official
Title or Position	:	OWNER
Name	:	MS. MARIANNE KRISTINE MILANES
Credential	:
Telephone Number	:	775-292-3535

Provider Enumeration Date	:	08/11/2023
Last Update Date	:	08/11/2023

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