Provider Demographics
NPI:1336694546
Name:COUNTRY PINES MEMORY CARE, LLC
Entity Type:Organization
Organization Name:COUNTRY PINES MEMORY CARE, LLC
Other - Org Name:COUNTRY PINES MEMORY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-425-3271
Mailing Address - Street 1:1748 W 1800 N
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8324
Mailing Address - Country:US
Mailing Address - Phone:801-774-9198
Mailing Address - Fax:801-825-3752
Practice Address - Street 1:1748 W 1800 N
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8324
Practice Address - Country:US
Practice Address - Phone:801-774-9198
Practice Address - Fax:801-825-3752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12-2014-509311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)