Provider Demographics
NPI:1629210083
Name:HERITAGE PARK REHABILITATION AND HEALTHCARE CENTER, LLC
Entity Type:Organization
Organization Name:HERITAGE PARK REHABILITATION AND HEALTHCARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7994
Mailing Address - Street 1:2700 W 5600 S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-1372
Mailing Address - Country:US
Mailing Address - Phone:801-825-9731
Mailing Address - Fax:801-766-2018
Practice Address - Street 1:2700 W 5600 S
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-1372
Practice Address - Country:US
Practice Address - Phone:801-825-9731
Practice Address - Fax:801-766-2018
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORIANNA HEALTH SYSTEMS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-01
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY128659500Medicaid
WY128659500Medicaid
UT=========001Medicaid