Provider Demographics
NPI:1639506884
Name:SPIRIT LAKE RANCH, LLC
Entity type:Organization
Organization Name:SPIRIT LAKE RANCH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:PATCHING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-615-0213
Mailing Address - Street 1:PO BOX 533
Mailing Address - Street 2:
Mailing Address - City:MONA
Mailing Address - State:UT
Mailing Address - Zip Code:84645-0533
Mailing Address - Country:US
Mailing Address - Phone:435-623-2825
Mailing Address - Fax:435-623-2827
Practice Address - Street 1:525 W 200 N
Practice Address - Street 2:
Practice Address - City:MONA
Practice Address - State:UT
Practice Address - Zip Code:84645
Practice Address - Country:US
Practice Address - Phone:435-623-2825
Practice Address - Fax:435-623-2827
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE JOURNEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-02
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20208253J00000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No253J00000XAgenciesFoster Care Agency