Provider Demographics
NPI:1376814160
Name:TIMPANOGOS TERRACE ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:TIMPANOGOS TERRACE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:RASBAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-683-9550
Mailing Address - Street 1:164 W 200 S
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2344
Mailing Address - Country:US
Mailing Address - Phone:801-216-4110
Mailing Address - Fax:801-877-2232
Practice Address - Street 1:164 W 200 S
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2344
Practice Address - Country:US
Practice Address - Phone:801-216-4110
Practice Address - Fax:801-877-2232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2012-ALII-87810310400000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No385H00000XRespite Care FacilityRespite Care