Basic Information
| Provider Information | |||||||||
| NPI: | 1639170384 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVALON CARE CENTER - CANYON RIM, LLC | ||||||||
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| OtherOrganizationName: | CANYON RIM CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 N 2100 W | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841162927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013250153 | ||||||||
| FaxNumber: | 8015969001 | ||||||||
| Practice Location | |||||||||
| Address1: | 2730 E 3300 S | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841092819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014870896 | ||||||||
| FaxNumber: | 8014870912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 05/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | LINCOLN | ||||||||
| AuthorizedOfficialFirstName: | FAYE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, POLICY/GOVERNMENT RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8013250153 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2004-NCF-105 | UT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 870426816000 | 05 | UT | MEDICAID |