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General NPI Number Information
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NPI Number | 1043070063
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Entity Type | Organization
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Legal Business Name | VIVID SAFE HOUSE
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Dates
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Enumeration Date | 03/19/2024
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Last Update Date | 03/19/2024
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Provider Practice Location Address
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Address Line | 3210 E BERNADA DRIVE
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City | SALT LAKE CITY
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State | UT
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Zip | 84124
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Country | US
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Telephone | 801-449-0089
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Fax |
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Provider Business Mailing Address
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Address Line | 4943 S WASATCH BLVD
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City | SALT LAKE CITY
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State | UT
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Zip | 84124-4798
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Country | US
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Telephone | 801-449-0089
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Fax |
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Authorized Official
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Title or Position | FINANCE DIRECTOR
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Name | STEVEN LABRUM
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Credential |
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Telephone | 801-718-0132
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State |
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