MEDICARE: METAMORPHOSIS OGDEN, 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	261QM2800X	Methadone Clinic	6264391-8913	UT

General Provider Information

NPI Number	:	1295804110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METAMORPHOSIS OGDEN, INC.

Provider Business Mailing Address
First Line	:	2557 LINCOLN AVENUE
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84401
Country	:	US
Telephone Number	:	801-622-5272
Fax Number	:	801-622-5256

Provider Business Practice Location Address
First Line	:	2144 WASHINGTON BLVD
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84401-1420
Country	:	US
Telephone Number	:	801-622-5272
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. SHANNON M. TERWEDO
Credential	:	M.P.A., FACHE
Telephone Number	:	801-622-5272

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	08/06/2015

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