MEDICARE: COUNTRY VIEW ASSISTED LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1063819761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY VIEW ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	2901 W CENTER ST
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84601-3659
Country	:	US
Telephone Number	:	801-377-7737
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 W CENTER ST
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84601-3659
Country	:	US
Telephone Number	:	801-377-7737
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOHN WAYNE BRAMALL
Credential	:
Telephone Number	:	435-673-5496

Provider Enumeration Date	:	11/24/2014
Last Update Date	:	11/24/2014

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