1730173725 NPI number — AVALON CARE CENTER-MADERA LLC

Table of content: (NPI 1730173725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730173725 NPI number — AVALON CARE CENTER-MADERA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVALON CARE CENTER-MADERA 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:
Provider Other Organization Name Type Code:
6
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:
1730173725
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:
84116-4740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-596-8844
Provider Business Mailing Address Fax Number:
801-596-9001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 HOWARD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADERA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93637-5131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-276-8765
Provider Business Practice Location Address Fax Number:
559-673-0753
Provider Enumeration Date:
09/06/2005

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:  040000166 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZR05191H , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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