Healthcare Provider Details

I. General information

NPI: 1326323114
Provider Name (Legal Business Name): COUNTRY NICHE ADULT DAY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2179 W 1800 N SUITE D
CLINTON UT
84015-7900
US

IV. Provider business mailing address

2179 W 1800 N SUITE D
CLINTON UT
84015-7900
US

V. Phone/Fax

Practice location:
  • Phone: 801-825-3582
  • Fax: 801-825-8536
Mailing address:
  • Phone: 801-825-3582
  • Fax: 801-825-8536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number17327
License Number StateUT

VIII. Authorized Official

Name: MR. PAUL ALLEN BURNETT
Title or Position: OWNER
Credential:
Phone: 801-825-3582