Provider Demographics
NPI:1861878266
Name:BEAVER VALLEY HOSPITAL
Entity type:Organization
Organization Name:BEAVER VALLEY HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TOBY
Authorized Official - Middle Name:
Authorized Official - Last Name:TILFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-471-0388
Mailing Address - Street 1:100 E SAN MARCOS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2986
Mailing Address - Country:US
Mailing Address - Phone:760-471-0388
Mailing Address - Fax:
Practice Address - Street 1:5540 S 1050 E
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7078
Practice Address - Country:US
Practice Address - Phone:801-479-8455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-07
Last Update Date:2016-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2015-NCF-306314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========029Medicaid
OH465117Medicare Oscar/Certification