Healthcare Provider Details

I. General information

NPI: 1578517546
Provider Name (Legal Business Name): CASTLE COUNTRY CARE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 E 300 N
PRICE UT
84501-2707
US

IV. Provider business mailing address

PO BOX 57850
MURRAY UT
84157-0850
US

V. Phone/Fax

Practice location:
  • Phone: 435-637-9213
  • Fax: 435-637-4976
Mailing address:
  • Phone: 801-268-1122
  • Fax: 801-268-1150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2005-NCF-32
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number2007-NCF-32
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number2007-NCF-32
License Number StateUT

VIII. Authorized Official

Name: CRAIG R JOHNSON
Title or Position: SEC / TREASURER
Credential:
Phone: 801-268-1122