Provider Demographics
NPI:1487160875
Name:DEER HOLLOW LAKESIDE LLC
Entity type:Organization
Organization Name:DEER HOLLOW LAKESIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCIAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROMANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-759-1734
Mailing Address - Street 1:PO BOX 1078
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-1078
Mailing Address - Country:US
Mailing Address - Phone:801-679-6669
Mailing Address - Fax:801-203-9216
Practice Address - Street 1:7904 S NORDIC TRAIL LN
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:UT
Practice Address - Zip Code:84121-1000
Practice Address - Country:US
Practice Address - Phone:801-679-6669
Practice Address - Fax:801-203-9216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-20
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53992324500000X
UT53972324500000X
UT51884324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility