=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558730218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DDMS OF UTAH NO.2
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2015
-----------------------------------------------------
Last Update Date | 06/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4028 S 4800 W
-----------------------------------------------------
City | WEST VALLEY CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84120-4537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-968-8122
-----------------------------------------------------
Fax | 801-968-8135
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4028 S 4800 W
-----------------------------------------------------
City | WEST VALLEY CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84120-4537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-968-8122
-----------------------------------------------------
Fax | 801-968-8135
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MISTI ANN BUCK
-----------------------------------------------------
Credential | D.O./ADMINISTRATOR
-----------------------------------------------------
Telephone | 801-763-9299
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 2015-SHCF-101
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------