Provider Demographics
NPI:1457354755
Name:WESTSIDE COMMUNITY NURSING CENTER
Entity Type:Organization
Organization Name:WESTSIDE COMMUNITY NURSING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-355-9649
Mailing Address - Street 1:876 W 700 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-1404
Mailing Address - Country:US
Mailing Address - Phone:801-355-9649
Mailing Address - Fax:801-531-7003
Practice Address - Street 1:876 W 700 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-1404
Practice Address - Country:US
Practice Address - Phone:801-355-9649
Practice Address - Fax:801-531-7003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========003Medicaid