Basic Information
| Provider Information | |||||||||
| NPI: | 1720266570 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RED ROCK CANYON SCHOOL NON PROFIT ORGANIZATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | RED ROCK CANYON SCHOOL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 747 E SAINT GEORGE BLVD | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847703035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356736111 | ||||||||
| FaxNumber: | 4356730994 | ||||||||
| Practice Location | |||||||||
| Address1: | 747 E SAINT GEORGE BLVD | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847703035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356736111 | ||||||||
| FaxNumber: | 4356730994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 06/25/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PACE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4356736111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MA ED, MC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 3648 | UT | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 54988322 | 05 | NM | MEDICAID | 100521047 | 05 | NV | MEDICAID |