MEDICARE: KEYSTONE FAMILY SUPPORT, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	12525	UT

General Provider Information

NPI Number	:	1033592290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEYSTONE FAMILY SUPPORT, INC.

Provider Business Mailing Address
First Line	:	195 E 550 N
Second Line	:
City	:	FARMINGTON
State	:	UT
Zip	:	84025-2522
Country	:	US
Telephone Number	:	801-645-6451
Fax Number	:

Provider Business Practice Location Address
First Line	:	2558 VALLEY VIEW DR
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84040-7654
Country	:	US
Telephone Number	:	801-645-6451
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/DIRECTOR
Name	:	MS. HOLLY STOCK
Credential	:	TEACHER
Telephone Number	:	801-645-6451

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	07/07/2015

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