Provider Demographics
NPI:1386871853
Name:MYSTIC MOTION INC
Entity type:Organization
Organization Name:MYSTIC MOTION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRET
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:HINER
Authorized Official - Suffix:
Authorized Official - Credentials:LSAC,BRI-1
Authorized Official - Phone:801-631-7122
Mailing Address - Street 1:7602 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047
Mailing Address - Country:US
Mailing Address - Phone:801-631-7122
Mailing Address - Fax:877-840-9122
Practice Address - Street 1:7602 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047
Practice Address - Country:US
Practice Address - Phone:801-631-7122
Practice Address - Fax:877-840-9122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT15350324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility