Provider Demographics
NPI:1154389203
Name:ST GEORGE NURSING HOME LLC
Entity type:Organization
Organization Name:ST GEORGE NURSING HOME LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOPES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-688-1207
Mailing Address - Street 1:178 S 1200 E
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5508
Mailing Address - Country:US
Mailing Address - Phone:435-688-1207
Mailing Address - Fax:435-688-8650
Practice Address - Street 1:178 S 1200 E
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-5508
Practice Address - Country:US
Practice Address - Phone:435-688-1207
Practice Address - Fax:435-688-8650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-NCF-21909314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT=========001Medicaid