Provider Demographics
NPI:1639446297
Name:COUNTRY LIFE CARE CENTERS
Entity Type:Organization
Organization Name:COUNTRY LIFE CARE CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:F
Authorized Official - Last Name:BUCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:801-417-9400
Mailing Address - Street 1:13747 S REDWOOD RD.
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-5712
Mailing Address - Country:US
Mailing Address - Phone:801-417-9400
Mailing Address - Fax:801-417-9399
Practice Address - Street 1:13747 S REDWOOD RD.
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-5712
Practice Address - Country:US
Practice Address - Phone:801-417-9400
Practice Address - Fax:801-417-9399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT314000000X, 3140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT465179Medicare Oscar/Certification