Provider Demographics
NPI:1427115245
Name:KOSTOPULOS DREAM FOUNDATION
Entity type:Organization
Organization Name:KOSTOPULOS DREAM FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ETHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-582-0700
Mailing Address - Street 1:2500 EMIGRATION CYN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1517
Mailing Address - Country:US
Mailing Address - Phone:801-582-0700
Mailing Address - Fax:801-583-5176
Practice Address - Street 1:2500 EMIGRATION CYN
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1517
Practice Address - Country:US
Practice Address - Phone:801-582-0700
Practice Address - Fax:801-583-5176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTC126385HR2050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2050XRespite Care FacilityRespite CareRespite Care Camp