Provider Demographics
NPI:1144875766
Name:PICNIC CREEK LLC
Entity type:Organization
Organization Name:PICNIC CREEK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:JO
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-776-7000
Mailing Address - Street 1:1407 S 2000 W
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-6935
Mailing Address - Country:US
Mailing Address - Phone:801-776-7000
Mailing Address - Fax:801-776-9464
Practice Address - Street 1:1407 S 2000 W
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-6935
Practice Address - Country:US
Practice Address - Phone:801-776-7000
Practice Address - Fax:801-776-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No385H00000XRespite Care FacilityRespite Care