Healthcare Provider Details

I. General information

NPI: 1164970869
Provider Name (Legal Business Name): REDWOOD GROVE DIAGNOSTICS & TRANSITIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 S MAIN ST
SPRINGVILLE UT
84663-2452
US

IV. Provider business mailing address

757 S MAIN ST
SPRINGVILLE UT
84663-2452
US

V. Phone/Fax

Practice location:
  • Phone: 801-491-2270
  • Fax:
Mailing address:
  • Phone: 801-491-2270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER TOLEN
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 801-491-2270