Provider Demographics
NPI:1861034209
Name:CANON CITY NURSING AND REHAB CENTER, LLC
Entity Type:Organization
Organization Name:CANON CITY NURSING AND REHAB CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HIXSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-941-3495
Mailing Address - Street 1:1376 E 3300 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3069
Mailing Address - Country:US
Mailing Address - Phone:801-601-1450
Mailing Address - Fax:
Practice Address - Street 1:515 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2863
Practice Address - Country:US
Practice Address - Phone:801-601-1450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility