Organization
LIFE-LINE, INC.
Active
Other names
Lifeline for Youth
Organization subpart
No
Provider details
NPI number
Authorized official
MR. SHANE R PETERSEN MBA (CHIEF EXECUTIVE OFFICER)
(801) 936-4000
Entity
Organization
Contact information
Practice address
1130 W CENTER ST, NORTH SALT LAKE, UT 84054-2917
(801) 936-4000
Mailing address
1130 W CENTER ST, NORTH SALT LAKE, UT 84054-2917
(801) 936-4000
Taxonomy
Speciality
Code
Description
License number
State
261QM0855X
Adolescent and Children Mental Health Clinic/Center
11832
UT
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
11832
UT
Other
Enumeration date
10/09/2007
Last updated
10/21/2011
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