Provider Demographics
NPI:1386728749
Name:STORM RIDGE RANCH
Entity type:Organization
Organization Name:STORM RIDGE RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-527-3191
Mailing Address - Street 1:95 W 3000 N
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:UT
Mailing Address - Zip Code:84754-3270
Mailing Address - Country:US
Mailing Address - Phone:435-527-3191
Mailing Address - Fax:435-527-3076
Practice Address - Street 1:95 W 3000 N
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:UT
Practice Address - Zip Code:84754-3270
Practice Address - Country:US
Practice Address - Phone:435-527-3191
Practice Address - Fax:435-527-3076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11501322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT788007788059Medicaid