Provider Demographics
NPI:1992866024
Name:COUNTRY PINES RETIREMENT HOME
Entity Type:Organization
Organization Name:COUNTRY PINES RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:801-773-1649
Mailing Address - Street 1:1748 W 1800 N
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8324
Mailing Address - Country:US
Mailing Address - Phone:801-773-1649
Mailing Address - Fax:
Practice Address - Street 1:1748 W 1800 N
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8324
Practice Address - Country:US
Practice Address - Phone:801-773-1649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-AL1-540310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility