Provider Demographics
NPI:1205131091
Name:HENNEFER'S HOME FOR THE ELDERLY
Entity type:Organization
Organization Name:HENNEFER'S HOME FOR THE ELDERLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HENNEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-265-9617
Mailing Address - Street 1:1200 E 4500 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4127
Mailing Address - Country:US
Mailing Address - Phone:801-265-9617
Mailing Address - Fax:
Practice Address - Street 1:1200 E 4500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4127
Practice Address - Country:US
Practice Address - Phone:801-265-9617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2010-ALI-364310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility