Provider Demographics
NPI:1750732723
Name:COUNTRY LANE PAYSON OPERATING LLC
Entity type:Organization
Organization Name:COUNTRY LANE PAYSON OPERATING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-928-3997
Mailing Address - Street 1:1133 N. MAIN ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041
Mailing Address - Country:US
Mailing Address - Phone:801-546-7417
Mailing Address - Fax:801-546-5230
Practice Address - Street 1:153 S. 900 E
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651
Practice Address - Country:US
Practice Address - Phone:801-465-1490
Practice Address - Fax:801-465-3579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2016AL11UT207238310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility