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General NPI Number Information
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NPI Number | 1366863185
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Entity Type | Organization
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Legal Business Name | PINE RIDGE BEHAVIORAL HEALTH LLC
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Dates
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Enumeration Date | 12/20/2013
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Last Update Date | 06/18/2024
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Provider Practice Location Address
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Address Line | 10380 EAST 22000 NORTH
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City | FAIRVIEW
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State | UT
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Zip | 84629
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Country | US
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Telephone | 435-469-0342
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Fax |
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Provider Business Mailing Address
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Address Line | 10380 EAST 22000 NORTH
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City | FAIRVIEW
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State | UT
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Zip | 84629
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Country | US
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Telephone | 435-469-0342
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. JAMES R CHENEY II
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Credential |
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Telephone | 435-469-0342
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | 21289
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License Number State | UT
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