Provider Demographics
NPI:1316457443
Name:SEGO LILY ASSISTED LIVING
Entity type:Organization
Organization Name:SEGO LILY ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-367-8854
Mailing Address - Street 1:1350 N MANILA CT
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-9158
Mailing Address - Country:US
Mailing Address - Phone:801-367-8854
Mailing Address - Fax:801-701-2126
Practice Address - Street 1:465 E SEGO LILY DR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-3547
Practice Address - Country:US
Practice Address - Phone:801-367-8854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2017-ALI-UT207199310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility