Provider Demographics
NPI:1649454703
Name:THATCHER BROOK REHABILITATION AND CARE CENTER LLC
Entity type:Organization
Organization Name:THATCHER BROOK REHABILITATION AND CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEVEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-614-5700
Mailing Address - Street 1:PO BOX 160528
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84016
Mailing Address - Country:US
Mailing Address - Phone:801-614-5700
Mailing Address - Fax:801-614-5750
Practice Address - Street 1:1795 CHELEMES WAY
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-6298
Practice Address - Country:US
Practice Address - Phone:801-614-5700
Practice Address - Fax:801-614-5750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT465169Medicare Oscar/Certification
UT465169Medicare PIN