Provider Demographics
NPI:1023017340
Name:PARKDALE CARE CENTER, INC.
Entity type:Organization
Organization Name:PARKDALE CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BEAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-624-6230
Mailing Address - Street 1:4020 SIERRA COLLEGE BLVD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-3906
Mailing Address - Country:US
Mailing Address - Phone:916-624-6230
Mailing Address - Fax:916-624-6249
Practice Address - Street 1:250 E 600 N
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-2126
Practice Address - Country:US
Practice Address - Phone:435-637-2621
Practice Address - Fax:435-637-8979
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HORIZON WEST HEALTHCARE OF UTAH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-19
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-NCF-73314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT0684920001Medicare NSC
UT465102Medicare Oscar/Certification