Healthcare Provider Details

I. General information

NPI: 1043070063
Provider Name (Legal Business Name): VIVID SAFE HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 E BERNADA DRIVE
SALT LAKE CITY UT
84124
US

IV. Provider business mailing address

4943 S WASATCH BLVD
SALT LAKE CITY UT
84124-4798
US

V. Phone/Fax

Practice location:
  • Phone: 801-449-0089
  • Fax:
Mailing address:
  • Phone: 801-449-0089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: STEVEN LABRUM
Title or Position: FINANCE DIRECTOR
Credential:
Phone: 801-718-0132