Provider Demographics
NPI:1982972964
Name:LIGHTHOUSE RANCH
Entity type:Organization
Organization Name:LIGHTHOUSE RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-262-0891
Mailing Address - Street 1:PO BOX 461
Mailing Address - Street 2:21360 NORTH 1450 EAST
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646
Mailing Address - Country:US
Mailing Address - Phone:435-445-5200
Mailing Address - Fax:435-445-5201
Practice Address - Street 1:21360 N 1450 E
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646-0461
Practice Address - Country:US
Practice Address - Phone:435-445-5200
Practice Address - Fax:435-445-5201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1235458555Medicaid