Basic Information
| Provider Information | |||||||||
| NPI: | 1336387307 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCPHERSON CARE CENTER LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 500 N MARKET PLACE DR | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | CENTERVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840141708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012965105 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 N MARKET PLACE DR | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | CENTERVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840141708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012965105 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2009 | ||||||||
| LastUpdateDate: | 01/29/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAM | ||||||||
| AuthorizedOfficialFirstName: | TRUNG | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | DIR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8012965149 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DNR TWO LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 4263257 | KS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2004438960A | 05 | KS | MEDICAID |