Healthcare Provider Details

I. General information

NPI: 1255860763
Provider Name (Legal Business Name): WELBROOK SENIOR LIVING FLAGSTAFF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 N PINE CLIFF DR
FLAGSTAFF AZ
86001
US

IV. Provider business mailing address

450 S 400 E STE 200
BOUNTIFUL UT
84010-5094
US

V. Phone/Fax

Practice location:
  • Phone: 801-683-6565
  • Fax:
Mailing address:
  • Phone: 801-683-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MATT RASBAND
Title or Position: CEO
Credential:
Phone: 801-683-6565