Provider Demographics
NPI:1285635920
Name:BOUNTIFUL CARE CENTER, LLC
Entity Type:Organization
Organization Name:BOUNTIFUL CARE CENTER, LLC
Other - Org Name:AVALON CARE CENTER - BOUNTIFUL LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP POLICY/GOVERNMENT RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:FAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:LINCLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-325-0153
Mailing Address - Street 1:523 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6036
Mailing Address - Country:US
Mailing Address - Phone:801-951-1600
Mailing Address - Fax:801-951-1700
Practice Address - Street 1:523 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6036
Practice Address - Country:US
Practice Address - Phone:801-951-1600
Practice Address - Fax:801-951-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-NCF-59821314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========01Medicaid
UT465156Medicare Oscar/Certification