Provider Demographics
NPI:1477603652
Name:PEACHTREE PLACE VII LLC
Entity Type:Organization
Organization Name:PEACHTREE PLACE VII LLC
Other - Org Name:PEACHTREE PLACE OF WEST HAVEN
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ERNEST
Authorized Official - Last Name:PURVANCE
Authorized Official - Suffix:
Authorized Official - Credentials:DVM
Authorized Official - Phone:801-550-9135
Mailing Address - Street 1:4607 MIDLAND DR
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-9507
Mailing Address - Country:US
Mailing Address - Phone:801-732-0060
Mailing Address - Fax:801-732-0120
Practice Address - Street 1:4607 MIDLAND DR
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:UT
Practice Address - Zip Code:84401-9507
Practice Address - Country:US
Practice Address - Phone:801-732-0060
Practice Address - Fax:801-732-0120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-ALLL-9990310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility