Healthcare Provider Details

I. General information

NPI: 1376814160
Provider Name (Legal Business Name): TIMPANOGOS TERRACE ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 W 200 S
AMERICAN FORK UT
84003-2344
US

IV. Provider business mailing address

164 W 200 S
AMERICAN FORK UT
84003-2344
US

V. Phone/Fax

Practice location:
  • Phone: 801-216-4110
  • Fax: 801-877-2232
Mailing address:
  • Phone: 801-216-4110
  • Fax: 801-877-2232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2012-ALII-87810
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number2012-ALII-87810
License Number StateUT

VIII. Authorized Official

Name: MATT RASBAND
Title or Position: MANAGER
Credential:
Phone: 801-683-9550