Organization
LIGHTHOUSE RANCH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KEVIN ROGER BAILEY (PROGRAM DIRECTOR)
(435) 262-0891
Entity
Organization
Contact information
Practice address
21360 N 1450 E, MORONI, UT 84646-0461
(435) 445-5200
(435) 445-5201
Mailing address
PO BOX 461, 21360 NORTH 1450 EAST, MORONI, UT 84646
(435) 445-5200
(435) 445-5201
Taxonomy
Speciality
Code
Description
License number
State
3245S0500X
Children's Substance Abuse Rehabilitation Facility
Primary
—
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1235458555
—
UT
Enumeration date
12/06/2011
Last updated
12/06/2011
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