Healthcare Provider Details

I. General information

NPI: 1639506884
Provider Name (Legal Business Name): SPIRIT LAKE RANCH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W 200 N
MONA UT
84645
US

IV. Provider business mailing address

PO BOX 533
MONA UT
84645-0533
US

V. Phone/Fax

Practice location:
  • Phone: 435-623-2825
  • Fax: 435-623-2827
Mailing address:
  • Phone: 435-623-2825
  • Fax: 435-623-2827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number20208
License Number StateUT

VIII. Authorized Official

Name: TYLER PATCHING
Title or Position: CEO
Credential:
Phone: 801-615-0213