Provider Demographics
NPI:1356416283
Name:THE WENTWORTH AT COTTONWOOD HEIGHTS
Entity type:Organization
Organization Name:THE WENTWORTH AT COTTONWOOD HEIGHTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:N
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-557-3788
Mailing Address - Street 1:6895 WHITMORE WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3003
Mailing Address - Country:US
Mailing Address - Phone:801-943-3909
Mailing Address - Fax:801-943-1021
Practice Address - Street 1:6895 WHITMORE WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-3003
Practice Address - Country:US
Practice Address - Phone:801-943-3909
Practice Address - Fax:801-943-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid