Provider Demographics
NPI:1356335384
Name:AVALON CARE CENTER-SONORA LLC
Entity type:Organization
Organization Name:AVALON CARE CENTER-SONORA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CHAIRMAN
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:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4740
Mailing Address - Country:US
Mailing Address - Phone:801-596-8844
Mailing Address - Fax:801-596-9001
Practice Address - Street 1:19929 GREENLEY RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5996
Practice Address - Country:US
Practice Address - Phone:209-533-2500
Practice Address - Fax:209-533-0728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000674314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55736GMedicaid
UT555736Medicare Oscar/Certification