Provider Demographics
NPI:1891032553
Name:ASPEN WILDE RECOVERY
Entity type:Organization
Organization Name:ASPEN WILDE RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MAKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-427-2757
Mailing Address - Street 1:931 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-5203
Mailing Address - Country:US
Mailing Address - Phone:801-784-8329
Mailing Address - Fax:
Practice Address - Street 1:931 W CENTER ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-5203
Practice Address - Country:US
Practice Address - Phone:801-784-8329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20074261QR0405X
UT20073251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder