Healthcare Provider Details

I. General information

NPI: 1235793290
Provider Name (Legal Business Name): MOUNTAIN VALLEY RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 05/06/2024
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6910 N COWBOY LANE
HOLDEN UT
84636
US

IV. Provider business mailing address

275 W 100 S
DELTA UT
84624-9238
US

V. Phone/Fax

Practice location:
  • Phone: 435-253-0656
  • Fax:
Mailing address:
  • Phone: 435-406-4093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN E NIELSON
Title or Position: OWNER
Credential:
Phone: 435-406-4093