MEDICARE: EMPOWERED FOR LIFE, 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	20071054	UT

General Provider Information

NPI Number	:	1164673331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPOWERED FOR LIFE, LLC

Provider Business Mailing Address
First Line	:	1467 RIVERSIDE DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104-2116
Country	:	US
Telephone Number	:	801-244-6599
Fax Number	:	801-969-7105

Provider Business Practice Location Address
First Line	:	5004 WEST JANETTE DRIVE
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120
Country	:	US
Telephone Number	:	801-244-6599
Fax Number	:	801-969-7105

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. LINDA CASALLO
Credential	:
Telephone Number	:	801-244-6599

Provider Enumeration Date	:	10/07/2008
Last Update Date	:	10/07/2008

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