Provider Demographics
NPI:1851494710
Name:AVALON HILLS ADULT HEALTH CARE, INC
Entity Type:Organization
Organization Name:AVALON HILLS ADULT HEALTH CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENITA
Authorized Official - Middle Name:J
Authorized Official - Last Name:QUAKENBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-938-6060
Mailing Address - Street 1:PO BOX 3412
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84323-3412
Mailing Address - Country:US
Mailing Address - Phone:435-938-6060
Mailing Address - Fax:435-755-0439
Practice Address - Street 1:550 W MOUNT PISGAH RD
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:UT
Practice Address - Zip Code:84328
Practice Address - Country:US
Practice Address - Phone:435-938-6060
Practice Address - Fax:435-755-0439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11234323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT82090000001001OtherBLUE CROSS BLUE SHIELD