Provider Demographics
NPI:1043518145
Name:MEDALLION SUPPORTED LIVING-PAYSON
Entity Type:Organization
Organization Name:MEDALLION SUPPORTED LIVING-PAYSON
Other - Org Name:MEDALLION MANOR INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MERLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOYES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:801-375-2710
Mailing Address - Street 1:PO BOX 51377
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84605-1377
Mailing Address - Country:US
Mailing Address - Phone:801-375-2710
Mailing Address - Fax:801-377-3651
Practice Address - Street 1:2192 W STATE RD
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-4539
Practice Address - Country:US
Practice Address - Phone:801-375-2710
Practice Address - Fax:801-377-3651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2011-SHCF-100069315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities