Healthcare Provider Details

I. General information

NPI: 1063692804
Provider Name (Legal Business Name): SECOND NATURE ENTRADA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 SANTA CLARA DR SUITE 200
SANTA CLARA UT
84765-5466
US

IV. Provider business mailing address

2711 SANTA CLARA DR
SANTA CLARA UT
84765-5466
US

V. Phone/Fax

Practice location:
  • Phone: 435-674-9310
  • Fax: 435-674-9309
Mailing address:
  • Phone: 435-674-9310
  • Fax: 435-674-9309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number12776
License Number StateUT

VIII. Authorized Official

Name: MR. RICK L HEIZER
Title or Position: EXECUTIVE DIRECTOR
Credential: MS
Phone: 435-674-9310