MEDICARE: AVALON CARE CENTER - CANYON RIM, 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	314000000X	Skilled Nursing Facility	2004-NCF-105	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639170384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVALON CARE CENTER - CANYON RIM, LLC

Provider Business Mailing Address
First Line	:	206 N 2100 W
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-2927
Country	:	US
Telephone Number	:	801-325-0153
Fax Number	:	801-596-9001

Provider Business Practice Location Address
First Line	:	2730 E 3300 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2819
Country	:	US
Telephone Number	:	801-487-0896
Fax Number	:	801-487-0912

Authorized Official
Title or Position	:	VP, POLICY/GOVERNMENT RELATIONS
Name	:	FAYE LINCOLN
Credential	:
Telephone Number	:	801-325-0153

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	05/02/2016

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