Healthcare Provider Details

I. General information

NPI: 1003959149
Provider Name (Legal Business Name): LARRY LINDE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 EAST 1600 NORTH
SPANISH FORK UT
84660
US

IV. Provider business mailing address

PO BOX 117
SPANISH FORK UT
84660
US

V. Phone/Fax

Practice location:
  • Phone: 801-798-9077
  • Fax: 801-798-8949
Mailing address:
  • Phone: 801-798-9077
  • Fax: 801-798-8949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number11559
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number13995
License Number StateUT

VIII. Authorized Official

Name: CORBIN J LINDE
Title or Position: PRESIDENT
Credential:
Phone: 801-798-9077