Healthcare Provider Details

I. General information

NPI: 1831374768
Provider Name (Legal Business Name): SUMMIT LODGE RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 73B
FAIRVIEW UT
84629-9505
US

IV. Provider business mailing address

RR 1 BOX 73B
FAIRVIEW UT
84629-9505
US

V. Phone/Fax

Practice location:
  • Phone: 435-427-8808
  • Fax:
Mailing address:
  • Phone: 435-427-8808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number13564
License Number StateUT

VIII. Authorized Official

Name: DR. JOEL HANSON
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 435-427-8808