Organization
LEGACY VILLAGE HEALTHCARE LLC
Active
Parent organization
WESTERN STATES LODGING
Other names
Legacy Village for Rehabilitation & Memory Care
Organization subpart
Yes
Provider details
NPI number
Legal business name
WESTERN STATES LODGING
Authorized official
MR. PAUL C FAIRHOLM (MANAGING MEMBER)
(801) 269-0700
Entity
Organization
Contact information
Practice address
5472 S 3200 W, TAYLORSVILLE, UT 84129-7804
(801) 269-0700
(801) 269-1512
Mailing address
1018 ATHERTON DR, TAYLORSVILLE, UT 84123-3470
(801) 269-0700
(801) 269-1512
Taxonomy
Speciality
Code
Description
License number
State
311500000X
Alzheimer Center (Dementia Center)
TO BE DETERMINED
UT
314000000X
Skilled Nursing Facility
Primary
TO BE DETERMINED
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
113661303001
—
UT
05
—
800008673001
—
UT
05
—
870520717001
—
UT
05
—
870638970001
—
UT
Enumeration date
03/24/2008
Last updated
04/22/2015
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