Healthcare Provider Details

I. General information

NPI: 1952850760
Provider Name (Legal Business Name): AVALON HEALTH CARE - ROSE HAVEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 NW HILL AVE
ROSEBURG OR
97471-1672
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 801-596-8844
  • Fax:
Mailing address:
  • Phone: 801-596-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: FAYE LINCOLN
Title or Position: SVP GOVERNMENT RELATIONS
Credential:
Phone: 801-596-8844