Basic Information
| Provider Information | |||||||||
| NPI: | 1871570374 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST JORDAN CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5007 S MISSION DR | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645059404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162329573 | ||||||||
| FaxNumber: | 8162329596 | ||||||||
| Practice Location | |||||||||
| Address1: | 3350 W 7800 S | ||||||||
| Address2: | |||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840884506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012820686 | ||||||||
| FaxNumber: | 8012829767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KELSO | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8013891523 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 2004-NCF-470 | UT | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 742561471031 | 05 | UT | MEDICAID |