MEDICARE: DDMS OF UTAH NO.2

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	2015-SHCF-101	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558730218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DDMS OF UTAH NO.2

Provider Business Mailing Address
First Line	:	4028 S 4800 W
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-4537
Country	:	US
Telephone Number	:	801-968-8122
Fax Number	:	801-968-8135

Provider Business Practice Location Address
First Line	:	4028 S 4800 W
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-4537
Country	:	US
Telephone Number	:	801-968-8122
Fax Number	:	801-968-8135

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MISTI ANN BUCK
Credential	:	D.O./ADMINISTRATOR
Telephone Number	:	801-763-9299

Provider Enumeration Date	:	09/23/2015
Last Update Date	:	06/08/2023

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