Provider Demographics
NPI:1083671119
Name:CEDAR CITY NURSING HOME LLC
Entity Type:Organization
Organization Name:CEDAR CITY NURSING HOME LLC
Other - Org Name:KOLOB REGIONAL CARE & REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GLADE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-586-6481
Mailing Address - Street 1:411 W 1325 N
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-7720
Mailing Address - Country:US
Mailing Address - Phone:435-586-6481
Mailing Address - Fax:435-586-0363
Practice Address - Street 1:411 W 1325 N
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-7720
Practice Address - Country:US
Practice Address - Phone:435-586-6481
Practice Address - Fax:435-586-0363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-NCF-9975314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870317400001Medicaid
UT870317400001Medicaid
UT870317400001Medicaid