MEDICARE: WASATCH RECOVERY TREATMENT CENTER LLC

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	324500000X	Substance Abuse Rehabilitation Facility	18921	UT

General Provider Information

NPI Number	:	1407129901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASATCH RECOVERY TREATMENT CENTER LLC

Provider Business Mailing Address
First Line	:	8420 WASATCH BLVD
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-6043
Country	:	US
Telephone Number	:	801-901-0024
Fax Number	:	801-278-2724

Provider Business Practice Location Address
First Line	:	8420 WASATCH BLVD
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-6043
Country	:	US
Telephone Number	:	801-901-0024
Fax Number	:	801-278-2724

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	DR. DAVID HUNT WHITAKER
Credential	:	PSY.D, LPC
Telephone Number	:	801-828-7715

Provider Enumeration Date	:	02/14/2012
Last Update Date	:	04/04/2014

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