MEDICARE: AVALON HEALTH CARE - ROSE HAVEN, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	208D00000X	General Practice Physician
2	363LF0000X	Family Nurse Practitioner
3	363LG0600X	Gerontology Nurse Practitioner
4	207RG0300X	Geriatric Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1952850760
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVALON HEALTH CARE - ROSE HAVEN, LLC

Provider Business Mailing Address
First Line	:	206 N 2100 W
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-4740
Country	:	US
Telephone Number	:	801-596-8844
Fax Number	:

Provider Business Practice Location Address
First Line	:	740 NW HILL AVE
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97471-1672
Country	:	US
Telephone Number	:	801-596-8844
Fax Number	:

Authorized Official
Title or Position	:	SVP GOVERNMENT RELATIONS
Name	:	FAYE LINCOLN
Credential	:
Telephone Number	:	801-596-8844

Provider Enumeration Date	:	09/22/2016
Last Update Date	:	10/17/2016

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