Healthcare Provider Details

I. General information

NPI: 1629423280
Provider Name (Legal Business Name): UTAH ADDICTION CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2590 E PRAIRIE VIEW DR
EAGLE MOUNTAIN UT
84005-6096
US

IV. Provider business mailing address

2590 E PRAIRIE VIEW DR
EAGLE MOUNTAIN UT
84005-6096
US

V. Phone/Fax

Practice location:
  • Phone: 801-766-2233
  • Fax:
Mailing address:
  • Phone: 801-766-2233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number13999
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number21344
License Number StateUT

VIII. Authorized Official

Name: JEREMY QUENTIN BOBERG
Title or Position: OWNER
Credential: LCSW
Phone: 801-634-8938