Provider Demographics
NPI:1225030810
Name:FRIENDSHIP VILLA CARE CENTER INC
Entity type:Organization
Organization Name:FRIENDSHIP VILLA CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:MATJASICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-466-0966
Mailing Address - Street 1:PO BOX 65007
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84165-0007
Mailing Address - Country:US
Mailing Address - Phone:801-487-7887
Mailing Address - Fax:801-466-3634
Practice Address - Street 1:3094 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3834
Practice Address - Country:US
Practice Address - Phone:801-487-7887
Practice Address - Fax:801-466-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6170313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========008Medicaid