Provider Demographics
NPI:1316909575
Name:LIFE SKILLS VOCATIONAL CENTER
Entity type:Organization
Organization Name:LIFE SKILLS VOCATIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-254-2666
Mailing Address - Street 1:15173 ROSE CANYON RD
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84065-4482
Mailing Address - Country:US
Mailing Address - Phone:801-254-2666
Mailing Address - Fax:
Practice Address - Street 1:2656 W 1500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-4151
Practice Address - Country:US
Practice Address - Phone:801-977-3732
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid