Provider Demographics
NPI:1124644430
Name:RED PINE RTC
Entity type:Organization
Organization Name:RED PINE RTC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LAW
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:435-725-2831
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:FORT DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84026-0309
Mailing Address - Country:US
Mailing Address - Phone:435-725-2831
Mailing Address - Fax:435-722-4690
Practice Address - Street 1:550 SOUTH 6777 EAST
Practice Address - Street 2:
Practice Address - City:FORT DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84026
Practice Address - Country:US
Practice Address - Phone:435-722-9906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UTE INDIAN TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility