=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134594286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNTAIN BROOK OUTPATIENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2015
-----------------------------------------------------
Last Update Date | 12/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14048 S. HIGHWAY 89
-----------------------------------------------------
City | SPANISH FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84660-0361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-873-3199
-----------------------------------------------------
Fax | 801-873-3507
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 361
-----------------------------------------------------
City | SPANISH FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84660-0361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-873-3199
-----------------------------------------------------
Fax | 801-873-3507
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | BROOK JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-228-8470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------