Provider Demographics
NPI:1043070063
Name:VIVID SAFE HOUSE
Entity type:Organization
Organization Name:VIVID SAFE HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LABRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-718-0132
Mailing Address - Street 1:4943 S WASATCH BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-4798
Mailing Address - Country:US
Mailing Address - Phone:801-449-0089
Mailing Address - Fax:
Practice Address - Street 1:3210 E BERNADA DRIVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-449-0089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVA CARLSTON ACADEMY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children