Healthcare Provider Details

I. General information

NPI: 1982947347
Provider Name (Legal Business Name): LAVA HEIGHTS ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 E SPRING DR
TOQUERVILLE UT
84774
US

IV. Provider business mailing address

747 E SAINT GEORGE BLVD
SAINT GEORGE UT
84770-3035
US

V. Phone/Fax

Practice location:
  • Phone: 866-452-8772
  • Fax:
Mailing address:
  • Phone: 435-673-6111
  • Fax: 435-673-0994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number20523
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number20523
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number20523
License Number StateUT

VIII. Authorized Official

Name: BRIAN PACE
Title or Position: EXECUTIVE DIRECTOR
Credential: MA ED, MC
Phone: 435-673-6111