Organization
EAST LAKE CARE CENTER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CRAIG R JOHNSON (MEMBER)
(801) 268-1122
Entity
Organization
Contact information
Practice address
101 N 500 W, PROVO, UT 84601-2646
(801) 377-9661
(801) 377-9747
Mailing address
PO BOX 57850, MURRAY, UT 84157-0850
(801) 268-1122
(801) 268-1150
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
2004-NCF-292
UT
332BN1400X
Nursing Facility Supplies (DME)
2007-NCF-292
UT
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
2007-NCF-292
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
870439756011
—
UT
Enumeration date
05/22/2006
Last updated
01/03/2008
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