Provider Demographics
NPI:1528052891
Name:AVALON CARE CENTER-OTHELLO LLC
Entity type:Organization
Organization Name:AVALON CARE CENTER-OTHELLO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-596-8844
Mailing Address - Street 1:206 N 2100 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-2927
Mailing Address - Country:US
Mailing Address - Phone:801-325-0153
Mailing Address - Fax:801-596-9001
Practice Address - Street 1:495 N 13TH AVE
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1215
Practice Address - Country:US
Practice Address - Phone:509-488-9609
Practice Address - Fax:509-488-6191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1359314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4113593Medicaid
WA4113593Medicaid