Provider Demographics
NPI:1760594048
Name:UTAH STATE VETERANS NURSING HOME
Entity Type:Organization
Organization Name:UTAH STATE VETERANS NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-584-1900
Mailing Address - Street 1:700 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1104
Mailing Address - Country:US
Mailing Address - Phone:801-584-1900
Mailing Address - Fax:801-584-1960
Practice Address - Street 1:700 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1104
Practice Address - Country:US
Practice Address - Phone:801-584-1900
Practice Address - Fax:801-584-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
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
UT465150Medicare ID - Type Unspecified