Healthcare Provider Details

I. General information

NPI: 1013991256
Provider Name (Legal Business Name): SORENSONS RANCH SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N 100 E
KOOSHAREM UT
84744-7700
US

IV. Provider business mailing address

410 N 100 E P.O. BOX 440219
KOOSHAREM UT
84744-7700
US

V. Phone/Fax

Practice location:
  • Phone: 435-638-7318
  • Fax: 435-638-7582
Mailing address:
  • Phone: 435-638-7318
  • Fax: 435-638-7582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number8393
License Number StateUT

VIII. Authorized Official

Name: MR. SHANE SORENSON
Title or Position: DIRECTOR
Credential:
Phone: 435-638-7318