Provider Demographics
NPI:1720037856
Name:AVALON CARE CENTER - BOUNTIFUL 350 SOUTH, LLC
Entity Type:Organization
Organization Name:AVALON CARE CENTER - BOUNTIFUL 350 SOUTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. 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:801-596-0900
Practice Address - Street 1:350 S 400 E
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4932
Practice Address - Country:US
Practice Address - Phone:801-397-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT465163Medicare Oscar/Certification