Basic Information
Provider Information | |||||||||
NPI: | 1669471975 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FOUR CORNERS REGIONAL CARE CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4020 SIERRA COLLEGE BLVD | ||||||||
Address2: | SUITE #190 | ||||||||
City: | ROCKLIN | ||||||||
State: | CA | ||||||||
PostalCode: | 956773906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9166246230 | ||||||||
FaxNumber: | 9166246249 | ||||||||
Practice Location | |||||||||
Address1: | 818 N 400 W | ||||||||
Address2: |   | ||||||||
City: | BLANDING | ||||||||
State: | UT | ||||||||
PostalCode: | 845113417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4356782251 | ||||||||
FaxNumber: | 4356782326 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2005 | ||||||||
LastUpdateDate: | 06/10/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEAR | ||||||||
AuthorizedOfficialFirstName: | LARRY | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9166246230 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HORIZON WEST HEALTHCARE OF UTAH, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 2005-NCF-109 | UT | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.