Organization Name: | RENAISSANCE RANCH OGDEN |
NPI Number: | 1194101592 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | DAVID ROSE (EXECUTIVE DIRECTOR) |
Mailing Address: | 5677 S 1475 E Ste 4a South Ogden |
State: | UT US |
Postal Code: | 844037003 |
Phone Number: | 3852223737 |
Fax Number: | 3852223738 |
NPI Enumeration Date: | 08/07/2015 |
NPI Last Update Date: | 08/07/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YA0400X |
License Number: | 10068 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | UT |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Addiction (Substance Use Disorder) |
Taxonomy Definition: |