Healthcare Provider Details

I. General information

NPI: 1164794434
Provider Name (Legal Business Name): DE NOVO SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 E 3900 S SUITE 155
SALT LAKE CITY UT
84107-1677
US

IV. Provider business mailing address

339 E 3900 S SUITE 155
SALT LAKE CITY UT
84107-1677
US

V. Phone/Fax

Practice location:
  • Phone: 801-263-1056
  • Fax: 801-261-3701
Mailing address:
  • Phone: 801-263-1056
  • Fax: 801-261-3701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: JERRY COSTLEY
Title or Position: DIRECTOR / OWNER
Credential:
Phone: 801-263-1056