Healthcare Provider Details

I. General information

NPI: 1407288400
Provider Name (Legal Business Name): ELK RIDGE ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2013
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 W OLYMPIC DR
ELK RIDGE UT
84651-5712
US

IV. Provider business mailing address

218 W OLYMPIC DR
ELK RIDGE UT
84651-5712
US

V. Phone/Fax

Practice location:
  • Phone: 801-358-7343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRIS HERMANSEN
Title or Position: OWNER
Credential:
Phone: 801-358-7343