Provider Demographics
NPI:1588128680
Name:WEBER RECOVERY CENTER LLC
Entity type:Organization
Organization Name:WEBER RECOVERY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-675-5624
Mailing Address - Street 1:5330 S 900 E STE 170
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-3522
Mailing Address - Country:US
Mailing Address - Phone:801-746-0097
Mailing Address - Fax:
Practice Address - Street 1:2740 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-3320
Practice Address - Country:US
Practice Address - Phone:801-746-0097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1598087702Medicaid