MEDICARE: YOUTH FOUNDATIONS

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	19974	UT

General Provider Information

NPI Number	:	1750634382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUTH FOUNDATIONS

Provider Business Mailing Address
First Line	:	150 N STATE ST
Second Line	:
City	:	LA VERKIN
State	:	UT
Zip	:	84745-5503
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 N STATE ST
Second Line	:
City	:	LA VERKIN
State	:	UT
Zip	:	84745-5503
Country	:	US
Telephone Number	:	435-635-6000
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JADE ROBINSON
Credential	:
Telephone Number	:	702-219-4749

Provider Enumeration Date	:	10/19/2012
Last Update Date	:	10/19/2012

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Directions to “YOUTH FOUNDATIONS ” Practice Location

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