Basic Information
| Provider Information | |||||||||
| NPI: | 1952850760 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVALON HEALTH CARE - ROSE HAVEN, LLC | ||||||||
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| OtherOrganizationName: | ROSE HAVEN NURSING 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 740 NW HILL AVE | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974711672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015968844 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2016 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | LINCOLN | ||||||||
| AuthorizedOfficialFirstName: | FAYE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP GOVERNMENT RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8015968844 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.