Provider Demographics
NPI:1982812459
Name:RENAISSANCE REHABILITATION OF SOUTH JORDAN
Entity Type:Organization
Organization Name:RENAISSANCE REHABILITATION OF SOUTH JORDAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:CROOKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-920-9566
Mailing Address - Street 1:1043 RAYMOND RD
Mailing Address - Street 2:
Mailing Address - City:FRUIT HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84037-2249
Mailing Address - Country:US
Mailing Address - Phone:801-444-3233
Mailing Address - Fax:
Practice Address - Street 1:1371 WEST SOUTH JORDAN PARKWAY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095
Practice Address - Country:US
Practice Address - Phone:801-920-9566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility