Healthcare Provider Details

I. General information

NPI: 1629129689
Provider Name (Legal Business Name): SUBTENANT 1430 EAST 4500 SOUTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 EAST 4500 SOUTH
SALT LAKE CITY UT
84117-4208
US

IV. Provider business mailing address

6400 OAK CANYON 200
IRVINE CA
92618-5233
US

V. Phone/Fax

Practice location:
  • Phone: 801-272-8000
  • Fax: 801-272-4983
Mailing address:
  • Phone: 949-240-7200
  • Fax: 949-240-7270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number2011-HOSP-100053
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateUT

VIII. Authorized Official

Name: MR. THOMAS V CROAL
Title or Position: SVP & CFO
Credential:
Phone: 949-240-7200