Provider Demographics
NPI:1427454107
Name:METSUN HIGHLAND SLC UT SENIOR LIVING, LLC
Entity type:Organization
Organization Name:METSUN HIGHLAND SLC UT SENIOR LIVING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STANFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-424-2200
Mailing Address - Street 1:4650 S HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7064
Mailing Address - Country:US
Mailing Address - Phone:801-424-2200
Mailing Address - Fax:801-424-2203
Practice Address - Street 1:4650 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-7064
Practice Address - Country:US
Practice Address - Phone:801-424-2200
Practice Address - Fax:801-424-2203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2013-ALII-106495310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility