Basic Information
| Provider Information | |||||||||
| NPI: | 1437692241 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CIRQUE LODGE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | RR 3 BOX A10 | ||||||||
| Address2: | |||||||||
| City: | SUNDANCE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846048901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012229200 | ||||||||
| FaxNumber: | 8012220112 | ||||||||
| Practice Location | |||||||||
| Address1: | 3114 E IDA'S ROAD | ||||||||
| Address2: | |||||||||
| City: | SUNDANCE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012229200 | ||||||||
| FaxNumber: | 8012220112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2016 | ||||||||
| LastUpdateDate: | 11/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8012229200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 28275 | UT | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.