Healthcare Provider Details

I. General information

NPI: 1194101592
Provider Name (Legal Business Name): ROSE ROAD HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5677 S 1475 E STE 4A
SOUTH OGDEN UT
84403-7003
US

IV. Provider business mailing address

5677 S 1475 E STE 4A
SOUTH OGDEN UT
84403-7003
US

V. Phone/Fax

Practice location:
  • Phone: 385-222-3737
  • Fax: 385-222-3738
Mailing address:
  • Phone: 385-222-3737
  • Fax: 385-222-3738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10068
License Number StateUT

VIII. Authorized Official

Name: DAVID ROSE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 801-680-7805