Healthcare Provider Details

I. General information

NPI: 1710344585
Provider Name (Legal Business Name): RENAISSANCE RANCH OUTPATIENT TREATMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 W 800 N STE 202
OREM UT
84057-3762
US

IV. Provider business mailing address

591 W 800 N STE 202
OREM UT
84057-3762
US

V. Phone/Fax

Practice location:
  • Phone: 801-572-4325
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number4625
License Number StateUT

VIII. Authorized Official

Name: CHERYL WACK
Title or Position: BILLING MANAGER
Credential:
Phone: 801-381-2928