Provider Demographics
NPI:1912241001
Name:OVERLAKE TERRACE ASSISTED LIVING
Entity Type:Organization
Organization Name:OVERLAKE TERRACE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:C
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-790-4652
Mailing Address - Street 1:2825 E COTTONWOOD PKWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-7055
Mailing Address - Country:US
Mailing Address - Phone:801-790-4652
Mailing Address - Fax:801-214-1970
Practice Address - Street 1:2825 E COTTONWOOD PKWY
Practice Address - Street 2:SUITE 500
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-7055
Practice Address - Country:US
Practice Address - Phone:801-790-4652
Practice Address - Fax:801-214-1970
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STELLAR SENIOR LIVING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603224991310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility