Provider Demographics
NPI:1205177722
Name:AVALON CARE CENTER - VA PAYSON LLC
Entity Type:Organization
Organization Name:AVALON CARE CENTER - VA PAYSON LLC
Other - Org Name:MERVYN SHARP BENNION CENTRAL UTAH VETERANS HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-596-8844
Mailing Address - Street 1:206 N 2100 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4740
Mailing Address - Country:US
Mailing Address - Phone:801-596-8844
Mailing Address - Fax:801-596-9001
Practice Address - Street 1:1551 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651
Practice Address - Country:US
Practice Address - Phone:801-596-8844
Practice Address - Fax:801-596-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT465181Medicare Oscar/Certification