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General NPI Number Information
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NPI Number | 1891921086
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Entity Type | Organization
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Legal Business Name | COLD CREEK WELLNESS CENTER
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Dates
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Enumeration Date | 06/02/2009
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Last Update Date | 12/29/2016
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Provider Practice Location Address
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Address Line | 845 W 200 N
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City | KAYSVILLE
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State | UT
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Zip | 84037-2406
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Country | US
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Telephone | 801-593-6777
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 640
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City | KAYSVILLE
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State | UT
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Zip | 84037-0640
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Country | US
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Telephone | 801-593-6777
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. TYLER DALLAS
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Credential |
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Telephone | 801-593-6777
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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 | 15305
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License Number State | UT
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