Basic Information
Provider Information | |||||||||
NPI: | 1326456443 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | S-H OPCO BEAR CREEK, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BEAR CREEK SENIOR LIVING SNF | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4525 S WASATCH BLVD, STE 300 | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 84124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8014957000 | ||||||||
FaxNumber: | 8021214970 | ||||||||
Practice Location | |||||||||
Address1: | 1685 S 21ST ST | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809045123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7193291774 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2014 | ||||||||
LastUpdateDate: | 08/08/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BENTON | ||||||||
AuthorizedOfficialFirstName: | ADAM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED SIGNER | ||||||||
AuthorizedOfficialTelephone: | 8016390446 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.