Basic Information
| Provider Information | |||||||||
| NPI: | 1477886059 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUE MOUNTAIN FAMILY CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WILDERNESS QUEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12 | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845350012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4355872801 | ||||||||
| FaxNumber: | 8012961715 | ||||||||
| Practice Location | |||||||||
| Address1: | 580 NORTH MAIN | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4355872801 | ||||||||
| FaxNumber: | 8012961715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2009 | ||||||||
| LastUpdateDate: | 09/14/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GILLIES | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING CONSULTANT | ||||||||
| AuthorizedOfficialTelephone: | 8019512317 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | UT | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.