Provider Demographics
NPI:1689675340
Name:AVALON CARE CENTER-WILLOW WOOD, INC
Entity Type:Organization
Organization Name:AVALON CARE CENTER-WILLOW WOOD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, POLICY/GOVERNMENT RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:FAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:LINCOLN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-325-0153
Mailing Address - Street 1:206 N 2100 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4740
Mailing Address - Country:US
Mailing Address - Phone:801-325-0153
Mailing Address - Fax:801-596-9001
Practice Address - Street 1:1205 E 4725 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4917
Practice Address - Country:US
Practice Address - Phone:801-262-2908
Practice Address - Fax:801-262-2963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2004-NCF-481314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========007Medicaid
UT465074Medicare Oscar/Certification