=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679282370
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALL GROWN UP IRON GATE CAMPUS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2022
-----------------------------------------------------
Last Update Date | 12/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 N 200 W
-----------------------------------------------------
City | CEDAR CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84720-2536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-868-8391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 N 200 W
-----------------------------------------------------
City | CEDAR CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84720-2536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-868-8391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KADE JANES
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 480-338-2176
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------