Provider Demographics
NPI:1669471975
Name:FOUR CORNERS REGIONAL CARE CENTER, INC.
Entity Type:Organization
Organization Name:FOUR CORNERS REGIONAL CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BEAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-624-6230
Mailing Address - Street 1:4020 SIERRA COLLEGE BLVD
Mailing Address - Street 2:SUITE #190
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-3906
Mailing Address - Country:US
Mailing Address - Phone:916-624-6230
Mailing Address - Fax:916-624-6249
Practice Address - Street 1:818 N 400 W
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3417
Practice Address - Country:US
Practice Address - Phone:435-678-2251
Practice Address - Fax:435-678-2326
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HORIZON WEST HEALTHCARE OF UTAH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-19
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-NCF-109310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========006Medicaid
UT0684940001Medicare NSC
UT=========006Medicaid