1508850876 NPI number — AVALON CARE CENTER-PASCO LLC

Table of content: (NPI 1508850876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508850876 NPI number — AVALON CARE CENTER-PASCO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVALON CARE CENTER-PASCO LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AVALON HEALTH & REHABILITATION CENTER - PASCO
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508850876
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 N 2100 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84116-2927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-325-0155
Provider Business Mailing Address Fax Number:
801-596-9001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2004 N 22ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASCO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99301-3313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-547-8811
Provider Business Practice Location Address Fax Number:
509-545-6276
Provider Enumeration Date:
09/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KIRTON
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/CHAIRMAN
Authorized Official Telephone Number:
801-596-8844

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH 1362 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4113627 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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