Healthcare Provider Details

I. General information

NPI: 1922492057
Provider Name (Legal Business Name): LIVE FOR LIFE CYPRESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 N BRONZEWOOD CIR
ERDA UT
84074-3302
US

IV. Provider business mailing address

3023 N BRONZEWOOD CIR
ERDA UT
84074-3302
US

V. Phone/Fax

Practice location:
  • Phone: 801-577-4142
  • Fax:
Mailing address:
  • Phone: 801-577-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number9716
License Number StateUT

VIII. Authorized Official

Name: TROY SHAW
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 801-577-4142