Provider Demographics
NPI:1437501772
Name:COUNTRY LANE MOUNT PLEASANT OPERATING LLC
Entity Type:Organization
Organization Name:COUNTRY LANE MOUNT PLEASANT OPERATING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-928-3997
Mailing Address - Street 1:1133 N MAIN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4800
Mailing Address - Country:US
Mailing Address - Phone:801-546-7417
Mailing Address - Fax:801-546-5230
Practice Address - Street 1:160 E 200 N
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647-1201
Practice Address - Country:US
Practice Address - Phone:435-462-9494
Practice Address - Fax:801-546-5230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility