Provider Demographics
NPI:1952850760
Name:AVALON HEALTH CARE - ROSE HAVEN, LLC
Entity Type:Organization
Organization Name:AVALON HEALTH CARE - ROSE HAVEN, LLC
Other - Org Name:ROSE HAVEN NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP 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:801-596-8844
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:801-596-8844
Mailing Address - Fax:
Practice Address - Street 1:740 NW HILL AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1672
Practice Address - Country:US
Practice Address - Phone:801-596-8844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty