Healthcare Provider Details

I. General information

NPI: 1558280974
Provider Name (Legal Business Name): 1925 N STATE STREET OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 N STATE ST
OREM UT
84057-2057
US

IV. Provider business mailing address

24901 DANA POINT HARBOR DR STE A200
DANA POINT CA
92629-2930
US

V. Phone/Fax

Practice location:
  • Phone: 801-494-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: CANDICE FINE
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 602-900-9020