=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134318546
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOW SPRINGS ESTATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2007
-----------------------------------------------------
Last Update Date | 10/22/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1025 W. 470 N.
-----------------------------------------------------
City | PRICE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-636-4483
-----------------------------------------------------
Fax | 435-613-0423
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1025 W. 470 N.
-----------------------------------------------------
City | PRICE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-636-4483
-----------------------------------------------------
Fax | 435-613-0423
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DALLEN KEITH SKELLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 435-340-1160
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------