Healthcare Provider Details

I. General information

NPI: 1215921242
Provider Name (Legal Business Name): AVALON CARE CENTER-SAN ANDREAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MOUNTAIN RANCH RD
SAN ANDREAS CA
95249-9713
US

IV. Provider business mailing address

206 N 2100 W
SALT LAKE CITY UT
84116-4740
US

V. Phone/Fax

Practice location:
  • Phone: 209-754-3823
  • Fax: 209-754-5621
Mailing address:
  • Phone: 801-596-8844
  • Fax: 801-596-9001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number030000135
License Number StateCA

VIII. Authorized Official

Name: CHARLES KIRTON
Title or Position: CEO/CHAIRMAN
Credential:
Phone: 801-596-8844