Provider Demographics
NPI:1588665236
Name:AVALON CARE CENTER - BRIGHAM CITY, L.L.C.
Entity Type:Organization
Organization Name:AVALON CARE CENTER - BRIGHAM CITY, L.L.C.
Other - Org Name:PIONEER CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP POLICY GOVERNMENT RELATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:FAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:LINCOLN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-325-0153
Mailing Address - Street 1:206 N 2100 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4740
Mailing Address - Country:US
Mailing Address - Phone:801-325-0153
Mailing Address - Fax:801-596-9001
Practice Address - Street 1:815 S 200 W
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3333
Practice Address - Country:US
Practice Address - Phone:435-723-5280
Practice Address - Fax:435-723-0579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2004-NCF-76314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870530623008Medicaid
UT465020Medicare Oscar/Certification
UT465020Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER