Basic Information
| Provider Information | |||||||||
| NPI: | 1750375846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVALON CARE CENTER-NEWMAN LLC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | SAN LUIS CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 N 2100 W | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841164740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015968844 | ||||||||
| FaxNumber: | 8015969001 | ||||||||
| Practice Location | |||||||||
| Address1: | 709 N ST | ||||||||
| Address2: | |||||||||
| City: | NEWMAN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953601162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098622862 | ||||||||
| FaxNumber: | 2098624631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIRTON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 8015968844 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 030000128 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZR05839H | 05 | CA | MEDICAID |