Provider Demographics
NPI:1194101592
Name:ROSE ROAD HOME LLC
Entity type:Organization
Organization Name:ROSE ROAD HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-680-7805
Mailing Address - Street 1:5677 S 1475 E STE 4A
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-7003
Mailing Address - Country:US
Mailing Address - Phone:385-222-3737
Mailing Address - Fax:385-222-3738
Practice Address - Street 1:5677 S 1475 E STE 4A
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-7003
Practice Address - Country:US
Practice Address - Phone:385-222-3737
Practice Address - Fax:385-222-3738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10068101YA0400X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty