Basic Information
| Provider Information | |||||||||
| NPI: | 1962746222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DESERET HEALTH AND REHAB AT ROCK SPRINGS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 SAGE ST | ||||||||
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| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829017478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073623780 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1325 SAGE ST | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829017478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073623780 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2012 | ||||||||
| LastUpdateDate: | 06/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | GARRETT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8012965105 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DNR TWO LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 106152600 | 05 | WY | MEDICAID |