Provider Demographics
NPI:1518525989
Name:PETERSEN FARMS ASSISTED LIVING & MEMORY CARE
Entity Type:Organization
Organization Name:PETERSEN FARMS ASSISTED LIVING & MEMORY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:CROXFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-388-3848
Mailing Address - Street 1:6980 S. 475 E.
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEBER
Mailing Address - State:UT
Mailing Address - Zip Code:84405
Mailing Address - Country:US
Mailing Address - Phone:801-479-6000
Mailing Address - Fax:
Practice Address - Street 1:6980 S. 475 E.
Practice Address - Street 2:
Practice Address - City:SOUTH WEBER
Practice Address - State:UT
Practice Address - Zip Code:84405
Practice Address - Country:US
Practice Address - Phone:801-479-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility