Healthcare Provider Details

I. General information

NPI: 1154531309
Provider Name (Legal Business Name): KRIS' CAMP/ THERAPY INTENSIVE PROGRAMS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25955 CEDAR ST
IDYLLWILD CA
92549-5840
US

IV. Provider business mailing address

3359 CREEK RD
SALT LAKE CITY UT
84121
US

V. Phone/Fax

Practice location:
  • Phone: 801-598-7735
  • Fax: 801-942-1750
Mailing address:
  • Phone: 807-733-0721
  • Fax: 807-942-1750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-0016091
License Number StateFL

VIII. Authorized Official

Name: MRS. LIEDY VAN ISPELEW
Title or Position: ASSISTANT DIRECTOR
Credential:
Phone: 801-733-0721