Provider Demographics
NPI:1437118270
Name:CORAL DESERT REHABILITATION
Entity Type:Organization
Organization Name:CORAL DESERT REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:FLYGARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-674-5195
Mailing Address - Street 1:1490 E FOREMASTER DR
Mailing Address - Street 2:BUILDING B
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4488
Mailing Address - Country:US
Mailing Address - Phone:435-674-5195
Mailing Address - Fax:435-773-9580
Practice Address - Street 1:1490 E FOREMASTER DR
Practice Address - Street 2:BUILDING B
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4488
Practice Address - Country:US
Practice Address - Phone:435-674-5195
Practice Address - Fax:435-773-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT=========001Medicaid