Healthcare Provider Details

I. General information

NPI: 1558730218
Provider Name (Legal Business Name): DDMS OF UTAH NO.2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4028 S 4800 W
WEST VALLEY CITY UT
84120-4537
US

IV. Provider business mailing address

4028 S 4800 W
WEST VALLEY CITY UT
84120-4537
US

V. Phone/Fax

Practice location:
  • Phone: 801-968-8122
  • Fax: 801-968-8135
Mailing address:
  • Phone: 801-968-8122
  • Fax: 801-968-8135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number2015-SHCF-101
License Number StateUT

VIII. Authorized Official

Name: MISTI ANN BUCK
Title or Position: DIRECTOR OF OPERATIONS
Credential: D.O./ADMINISTRATOR
Phone: 801-763-9299