Provider Demographics
NPI:1629129689
Name:SUBTENANT 1430 EAST 4500 SOUTH LLC
Entity Type:Organization
Organization Name:SUBTENANT 1430 EAST 4500 SOUTH LLC
Other - Org Name:ASPEN PARK REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:V
Authorized Official - Last Name:CROAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-240-7200
Mailing Address - Street 1:6400 OAK CANYON
Mailing Address - Street 2:200
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-5233
Mailing Address - Country:US
Mailing Address - Phone:949-240-7200
Mailing Address - Fax:949-240-7270
Practice Address - Street 1:1430 EAST 4500 SOUTH
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4208
Practice Address - Country:US
Practice Address - Phone:801-272-8000
Practice Address - Fax:801-272-4983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2011-HOSP-100053283Q00000X
UT314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT911982083003Medicaid
UT46-5162Medicare PIN
UT465162Medicare Oscar/Certification
UT911982083Medicare UPIN