MEDICARE: AVALON HEALTH CARE - ROSE HAVEN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1225581242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVALON HEALTH CARE - ROSE HAVEN LLC

Provider Business Mailing Address
First Line	:	206 N 2100 W
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-4740
Country	:	US
Telephone Number	:	801-596-8844
Fax Number	:	801-596-9001

Provider Business Practice Location Address
First Line	:	740 NW HILL AVE
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97471-1672
Country	:	US
Telephone Number	:	541-464-7100
Fax Number	:

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

Provider Enumeration Date	:	07/26/2016
Last Update Date	:	08/17/2022

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