Healthcare Provider Details

I. General information

NPI: 1326093261
Provider Name (Legal Business Name): EAST LAKE CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N 500 W
PROVO UT
84601-2646
US

IV. Provider business mailing address

PO BOX 57850
MURRAY UT
84157-0850
US

V. Phone/Fax

Practice location:
  • Phone: 801-377-9661
  • Fax: 801-377-9747
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 Number2004-NCF-292
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number2007-NCF-292
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number2007-NCF-292
License Number StateUT

VIII. Authorized Official

Name: CRAIG R JOHNSON
Title or Position: MEMBER
Credential:
Phone: 801-268-1122