Healthcare Provider Details

I. General information

NPI: 1669471975
Provider Name (Legal Business Name): FOUR CORNERS REGIONAL CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 N 400 W
BLANDING UT
84511-3417
US

IV. Provider business mailing address

4020 SIERRA COLLEGE BLVD SUITE #190
ROCKLIN CA
95677-3906
US

V. Phone/Fax

Practice location:
  • Phone: 435-678-2251
  • Fax: 435-678-2326
Mailing address:
  • Phone: 916-624-6230
  • Fax: 916-624-6249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2005-NCF-109
License Number StateUT

VIII. Authorized Official

Name: MR. LARRY E BEAR
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 916-624-6230