Provider Demographics
NPI:1598764862
Name:PROVO CARE CENTER
Entity Type:Organization
Organization Name:PROVO CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:PLANT
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:180-373-8771
Mailing Address - Street 1:PO BOX 1933
Mailing Address - Street 2:256 EAST CENTER STREET
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84603-1933
Mailing Address - Country:US
Mailing Address - Phone:180-137-3877
Mailing Address - Fax:180-137-3326
Practice Address - Street 1:256 E CENTER ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3107
Practice Address - Country:US
Practice Address - Phone:180-137-3877
Practice Address - Fax:180-137-3326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2004-NCF-79315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========OtherEIN
UT=========017Medicaid