1326410960 NPI number — THE PHOENIX RECOVERY & COUNSELING CENTER - VERNAL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326410960 NPI number — THE PHOENIX RECOVERY & COUNSELING CENTER - VERNAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PHOENIX RECOVERY & COUNSELING CENTER - VERNAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326410960
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1783 W 1000 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERNAL
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84078-4115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-709-8399
Provider Business Mailing Address Fax Number:
801-619-2016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1783 W 1000 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERNAL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84078-4115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-709-8399
Provider Business Practice Location Address Fax Number:
801-619-2016
Provider Enumeration Date:
10/22/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHRISTENSEN
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
RANDALL
Authorized Official Title or Position:
OPERATIONS DIRECTOR
Authorized Official Telephone Number:
435-773-5857

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  14091 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 14091 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 14091 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X , with the licence number: 14091 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X , with the licence number: 14091 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X , with the licence number: 14091 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)