Provider Demographics
NPI:1326093261
Name:EAST LAKE CARE CENTER, LLC
Entity Type:Organization
Organization Name:EAST LAKE CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-268-1122
Mailing Address - Street 1:PO BOX 57850
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84157-0850
Mailing Address - Country:US
Mailing Address - Phone:801-268-1122
Mailing Address - Fax:801-268-1150
Practice Address - Street 1:101 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2646
Practice Address - Country:US
Practice Address - Phone:801-377-9661
Practice Address - Fax:801-377-9747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2004-NCF-292314000000X
UT2007-NCF-292332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870439756011Medicaid
UT870439756011Medicaid
UT5706550001Medicare NSC