Healthcare Provider Details

I. General information

NPI: 1891032553
Provider Name (Legal Business Name): ASPEN WILDE RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 01/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 W CENTER ST
OREM UT
84057-5203
US

IV. Provider business mailing address

931 W CENTER ST
OREM UT
84057-5203
US

V. Phone/Fax

Practice location:
  • Phone: 801-784-8329
  • Fax:
Mailing address:
  • Phone: 801-784-8329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number20073
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number20074
License Number StateUT

VIII. Authorized Official

Name: MRS. JENNIFER ANN MAKIN
Title or Position: PRESIDENT / GENERAL MANAGER
Credential:
Phone: 801-427-2757