1154531309 NPI number — KRIS' CAMP/ THERAPY INTENSIVE PROGRAMS, INC

Table of content: (NPI 1154531309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154531309 NPI number — KRIS' CAMP/ THERAPY INTENSIVE PROGRAMS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KRIS' CAMP/ THERAPY INTENSIVE PROGRAMS, INC
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:
6
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:
1154531309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3359 CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
807-733-0721
Provider Business Mailing Address Fax Number:
807-942-1750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25955 CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDYLLWILD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92549-5840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-598-7735
Provider Business Practice Location Address Fax Number:
801-942-1750
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VAN ISPELEW
Authorized Official First Name:
LIEDY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT DIRECTOR
Authorized Official Telephone Number:
801-733-0721

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT-0016091 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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