Healthcare Provider Details

I. General information

NPI: 1912108242
Provider Name (Legal Business Name): CIRQUE LODGE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 11/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N PALISADES DR
OREM UT
84097-4341
US

IV. Provider business mailing address

777 N PALISADES DR
OREM UT
84097-4341
US

V. Phone/Fax

Practice location:
  • Phone: 801-222-9200
  • Fax: 801-222-0112
Mailing address:
  • Phone: 801-222-9200
  • Fax: 801-222-0112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number12370
License Number StateUT

VIII. Authorized Official

Name: GARY FISHER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 801-222-9200