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General NPI Number Information
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NPI Number | 1356772537
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Entity Type | Organization
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Legal Business Name | THISTLE CREEK RANCH
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Dates
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Enumeration Date | 12/12/2013
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Last Update Date | 12/12/2013
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Provider Practice Location Address
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Address Line | 14048 SOUTH HIGHWAY 89
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City | SPANISH FORK
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State | UT
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Zip | 84660
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Country | US
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Telephone | 801-873-3199
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Fax | 801-873-3507
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Provider Business Mailing Address
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Address Line | PO BOX 542
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City | SPANISH FORK
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State | UT
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Zip | 84660-0542
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Country | US
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Telephone | 801-873-3199
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Fax | 801-873-3507
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Authorized Official
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Title or Position | OWNER
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Name | SETH RIDDLE
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Credential | M.D.
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Telephone | 801-362-4900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 4381
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License Number State | UT
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