Provider Demographics
NPI:1457721789
Name:5STAR HOME OF SANDY
Entity type:Organization
Organization Name:5STAR HOME OF SANDY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:GUSTAVO
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-753-9130
Mailing Address - Street 1:465 E SEGO LILY DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3547
Mailing Address - Country:US
Mailing Address - Phone:801-523-8777
Mailing Address - Fax:801-523-1132
Practice Address - Street 1:465 E SEGO LILY DR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-3547
Practice Address - Country:US
Practice Address - Phone:801-523-8777
Practice Address - Fax:801-523-1132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2015-ALI-UT207199310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility