Healthcare Provider Details

I. General information

NPI: 1083932727
Provider Name (Legal Business Name): PIONEER YOUTH & ADULT COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 S MAIN ST STE 400
SALT LAKE CITY UT
84115-3578
US

IV. Provider business mailing address

PO BOX 651372
SALT LAKE CITY UT
84165-1372
US

V. Phone/Fax

Practice location:
  • Phone: 801-474-2500
  • Fax: 801-474-9117
Mailing address:
  • Phone: 801-474-2500
  • Fax: 801-474-9117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number16167
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number16168
License Number StateUT

VIII. Authorized Official

Name: MRS. LEIMA MUTI TUPUA
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-474-2500