Provider Demographics
NPI:1588272934
Name:SPLIT MOUNTAIN YOUTH CENTER
Entity type:Organization
Organization Name:SPLIT MOUNTAIN YOUTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-789-2045
Mailing Address - Street 1:830 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2708
Mailing Address - Country:US
Mailing Address - Phone:435-789-2045
Mailing Address - Fax:435-789-2245
Practice Address - Street 1:830 E MAIN ST
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2708
Practice Address - Country:US
Practice Address - Phone:435-789-2045
Practice Address - Fax:435-789-2245
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF UTAH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty