Provider Demographics
NPI:1720098163
Name:MEDALLION MANOR INC.
Entity Type:Organization
Organization Name:MEDALLION MANOR INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MERLIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-375-2710
Mailing Address - Street 1:PO BOX 51377
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84605-1377
Mailing Address - Country:US
Mailing Address - Phone:801-375-2710
Mailing Address - Fax:
Practice Address - Street 1:1701 W 600 S
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-3832
Practice Address - Country:US
Practice Address - Phone:801-375-2710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-NCF-69315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========009Medicaid