Provider Demographics
NPI:1104037563
Name:COUNTRY PINES PHASE II LC
Entity type:Organization
Organization Name:COUNTRY PINES PHASE II LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-773-0990
Mailing Address - Street 1:1706 W 1800 N
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8324
Mailing Address - Country:US
Mailing Address - Phone:801-773-0990
Mailing Address - Fax:
Practice Address - Street 1:1706 W 1800 N
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8324
Practice Address - Country:US
Practice Address - Phone:801-773-0990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT006871310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility