Healthcare Provider Details

I. General information

NPI: 1588292064
Provider Name (Legal Business Name): DIAMOND DETOX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4965 S 3500 W
ROY UT
84067-9417
US

IV. Provider business mailing address

845 W 200 N
KAYSVILLE UT
84037-2406
US

V. Phone/Fax

Practice location:
  • Phone: 385-888-9624
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JORDAN BURNINGHAM
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 801-330-3440