MEDICARE: PB UTAH SERVICES, 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

General Provider Information

NPI Number	:	1760969182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PB UTAH SERVICES, LLC

Provider Business Mailing Address
First Line	:	7444 LONG AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-3214
Country	:	US
Telephone Number	:	847-329-4100
Fax Number	:	847-329-4900

Provider Business Practice Location Address
First Line	:	8072 S HIGHLAND DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-5037
Country	:	US
Telephone Number	:	801-967-7664
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BENJAMIN KLEIN
Credential	:
Telephone Number	:	847-329-4100

Provider Enumeration Date	:	07/27/2018
Last Update Date	:	07/27/2018

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