Provider Demographics
NPI:1639634561
Name:LAYTON PARK MEMORY CARE
Entity Type:Organization
Organization Name:LAYTON PARK MEMORY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-546-7417
Mailing Address - Street 1:1133 N MAIN ST # 300
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4800
Mailing Address - Country:US
Mailing Address - Phone:801-546-7417
Mailing Address - Fax:801-546-5230
Practice Address - Street 1:101 N FORT LN
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5682
Practice Address - Country:US
Practice Address - Phone:801-823-3112
Practice Address - Fax:801-719-6473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTHT008073Medicaid