Basic Information
| Provider Information | |||||||||
| NPI: | 1710514765 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MG BOUNTIFUL SUBTENANT LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRUEWOOD BY MERRILL, BOUNTIFUL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1938 FAIRVIEW AVE E STE 300 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981023650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066765300 | ||||||||
| FaxNumber: | 2066765353 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840106351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012983241 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2020 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPEAR | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 2066765300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.