Healthcare Provider Details

I. General information

NPI: 1356476873
Provider Name (Legal Business Name): CROSS CREEK MANOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N STATE ST
LA VERKIN UT
84745-5503
US

IV. Provider business mailing address

50 S STATE ST
LA VERKIN UT
84745-5400
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 Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number12145
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number12143
License Number StateUT

VIII. Authorized Official

Name: MR. KARR FARNSWORTH
Title or Position: DIRECTOR
Credential:
Phone: 435-635-6003