Healthcare Provider Details

I. General information

NPI: 1679156004
Provider Name (Legal Business Name): RED TYDE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 N 700 W
HYDE PARK UT
84318
US

IV. Provider business mailing address

280 S MAIN ST
BOUNTIFUL UT
84010-6236
US

V. Phone/Fax

Practice location:
  • Phone: 435-213-3797
  • Fax:
Mailing address:
  • Phone: 801-505-0821
  • Fax: 801-505-0803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY M REDMOND
Title or Position: OWNER
Credential: PA-C
Phone: 435-213-3797