Healthcare Provider Details

I. General information

NPI: 1215642244
Provider Name (Legal Business Name): KIVA ADVENTURE RANCH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2023
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 N SHADY LN
TOQUERVILLE UT
84774-7741
US

IV. Provider business mailing address

PO BOX 39
TOQUERVILLE UT
84774-0039
US

V. Phone/Fax

Practice location:
  • Phone: 435-272-1492
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: LANA BAUER
Title or Position: INSURANCE MANAGER
Credential:
Phone: 435-592-1718