Healthcare Provider Details

I. General information

NPI: 1144875766
Provider Name (Legal Business Name): PICNIC CREEK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 S 2000 W
SYRACUSE UT
84075-6935
US

IV. Provider business mailing address

1407 S 2000 W
SYRACUSE UT
84075-6935
US

V. Phone/Fax

Practice location:
  • Phone: 801-776-7000
  • Fax: 801-776-9464
Mailing address:
  • Phone: 801-776-7000
  • Fax: 801-776-9464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: AIMEE JO RICE
Title or Position: ADMINISTRATOR
Credential:
Phone: 801-776-7000