Basic Information
| Provider Information | |||||||||
| NPI: | 1124234448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO TREATMENT OF UTAH LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BOUNTIFUL TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 MAITLAND CENTER PARKWAY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327514174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073517080 | ||||||||
| FaxNumber: | 4073516930 | ||||||||
| Practice Location | |||||||||
| Address1: | 763 W 700 S STE B | ||||||||
| Address2: | |||||||||
| City: | WOODS CROSS | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840871438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012922318 | ||||||||
| FaxNumber: | 8012922578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4073517080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METRO TREATMENT OF UT, LP | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 12047 | UT | N | Agencies | Community/Behavioral Health | 3336C0002X | 4970056-1704 | UT | N | Suppliers | Pharmacy | Clinic Pharmacy | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.