Healthcare Provider Details

I. General information

NPI: 1407529720
Provider Name (Legal Business Name): HOMERUN CRISIS INTERVENTION SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 07/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 QUARTER CIR
NIBLEY UT
84321-6317
US

IV. Provider business mailing address

PO BOX 437
HYRUM UT
84319-0437
US

V. Phone/Fax

Practice location:
  • Phone: 855-660-7200
  • Fax:
Mailing address:
  • Phone: 435-452-2662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGELA MARIE GARNER
Title or Position: COO
Credential: RN
Phone: 435-452-2662