MEDICARE: PEACHTREE PLACE VII LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	2005-ALLL-9990	UT

General Provider Information

NPI Number	:	1477603652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACHTREE PLACE VII LLC

Provider Business Mailing Address
First Line	:	4607 MIDLAND DR
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-9507
Country	:	US
Telephone Number	:	801-732-0060
Fax Number	:	801-732-0120

Provider Business Practice Location Address
First Line	:	4607 MIDLAND DR
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-9507
Country	:	US
Telephone Number	:	801-732-0060
Fax Number	:	801-732-0120

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. JONATHAN ERNEST PURVANCE
Credential	:	DVM
Telephone Number	:	801-550-9135

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	08/22/2020

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