Healthcare Provider Details

I. General information

NPI: 1780900464
Provider Name (Legal Business Name): CROSS CREEK MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 S STATE ST
LA VERKIN UT
84745-5443
US

IV. Provider business mailing address

50 S STATE ST
LA VERKIN UT
84745-5443
US

V. Phone/Fax

Practice location:
  • Phone: 435-635-2390
  • Fax: 435-635-2778
Mailing address:
  • Phone: 435-635-2390
  • Fax: 435-635-2778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number StateUT

VIII. Authorized Official

Name: DERRICK ESPLIN
Title or Position: CPA
Credential:
Phone: 435-635-2390