Healthcare Provider Details

I. General information

NPI: 1851711477
Provider Name (Legal Business Name): ADOLESCENT ESCORT SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 S CANTLE CIR
WASHINGTON UT
84780-2121
US

IV. Provider business mailing address

1865 S CANTLE CIR
WASHINGTON UT
84780-2121
US

V. Phone/Fax

Practice location:
  • Phone: 435-701-6984
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number1796
License Number StateUT

VIII. Authorized Official

Name: IAN GERRITSEN
Title or Position: OWNER
Credential:
Phone: 435-701-6984