Provider Demographics
NPI:1962543355
Name:COUNTRY VIEW MANOR INC
Entity type:Organization
Organization Name:COUNTRY VIEW MANOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-763-5040
Mailing Address - Street 1:2901 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-3659
Mailing Address - Country:US
Mailing Address - Phone:801-373-5079
Mailing Address - Fax:801-374-2855
Practice Address - Street 1:2901 W CENTER ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-3659
Practice Address - Country:US
Practice Address - Phone:801-373-5079
Practice Address - Fax:801-374-2855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========005Medicaid
UT=========005Medicaid