Provider Demographics
NPI:1962542217
Name:VISTA AT DIMPLE DELL CANYON
Entity type:Organization
Organization Name:VISTA AT DIMPLE DELL CANYON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:H MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:801-250-9762
Mailing Address - Street 1:10209 DIMPLE DELL RD
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-4536
Mailing Address - Country:US
Mailing Address - Phone:801-250-9762
Mailing Address - Fax:801-250-8483
Practice Address - Street 1:10209 DIMPLE DELL RD
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84092-4536
Practice Address - Country:US
Practice Address - Phone:801-250-9762
Practice Address - Fax:801-250-8483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12378322D00000X
UT12379323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Not Answered323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility