Provider Demographics
NPI:1972754133
Name:AVALON CARE CENTER - VA SALT LAKE II LLC
Entity Type:Organization
Organization Name:AVALON CARE CENTER - VA SALT LAKE II LLC
Other - Org Name:WILLIAM E. CHRISTOFFERSEN SALT LAKE VETERANS HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRTON
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:84116-2927
Mailing Address - Country:US
Mailing Address - Phone:801-325-0153
Mailing Address - Fax:801-433-0939
Practice Address - Street 1:700 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SLC
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:2008-10-07
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2007-NCF-933314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT465150Medicare Oscar/Certification