Healthcare Provider Details

I. General information

NPI: 1952792004
Provider Name (Legal Business Name): UTAH ADVOCACY NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 SOUTH BLUFF ROAD
SYRACUSE UT
84075-9214
US

IV. Provider business mailing address

2075 SOUTH BLUFF ROAD
SYRACUSE UT
84075-9214
US

V. Phone/Fax

Practice location:
  • Phone: 801-776-1380
  • Fax: 801-784-4900
Mailing address:
  • Phone: 801-776-1380
  • Fax: 801-784-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number189610-3102-20170122
License Number StateUT

VIII. Authorized Official

Name: MR. DAVID B. ANDREASEN
Title or Position: OWNER
Credential: QIDP DIRECTOR
Phone: 801-643-2866