Provider Demographics
NPI:1427290824
Name:WIDE HORIZONS RESIDENTIAL CARE FACILITY, LLC
Entity type:Organization
Organization Name:WIDE HORIZONS RESIDENTIAL CARE FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7994
Mailing Address - Street 1:910 MONROE BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-6434
Mailing Address - Country:US
Mailing Address - Phone:801-399-5876
Mailing Address - Fax:801-392-2955
Practice Address - Street 1:910 MONROE BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-6434
Practice Address - Country:US
Practice Address - Phone:801-399-5876
Practice Address - Fax:801-392-2955
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORIANNA HEALTH SYSTEMS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-31
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTAPPLIED FOR315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT208889Medicaid