Healthcare Provider Details

I. General information

NPI: 1548500614
Provider Name (Legal Business Name): FALCON RIDGE RANCH NON PROFIT ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 E HWY 9
VIRGIN UT
84779
US

IV. Provider business mailing address

PO BOX 790099
VIRGIN UT
84779-0099
US

V. Phone/Fax

Practice location:
  • Phone: 435-635-5260
  • Fax:
Mailing address:
  • Phone: 435-635-5260
  • Fax: 435-673-0994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number20004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number20004
License Number StateUT

VIII. Authorized Official

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