Healthcare Provider Details

I. General information

NPI: 1639446297
Provider Name (Legal Business Name): COUNTRY LIFE CARE CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13747 S REDWOOD RD.
RIVERTON UT
84065-5712
US

IV. Provider business mailing address

13747 S REDWOOD RD.
RIVERTON UT
84065-5712
US

V. Phone/Fax

Practice location:
  • Phone: 801-417-9400
  • Fax: 801-417-9399
Mailing address:
  • Phone: 801-417-9400
  • Fax: 801-417-9399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number
License Number StateUT

VIII. Authorized Official

Name: ROBERT F BUCKLEY
Title or Position: EXECUTIVE DIRECTOR
Credential: RN
Phone: 801-417-9400