MEDICARE: SUPERIOR 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	2007-AL1-72909	UT

General Provider Information

NPI Number	:	1235268202
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPERIOR ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	2499 CHARROS RD
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092-4815
Country	:	US
Telephone Number	:	801-495-1086
Fax Number	:

Provider Business Practice Location Address
First Line	:	2499 CHARROS RD
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092-4815
Country	:	US
Telephone Number	:	801-495-1086
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LORANT STEVE BODO
Credential	:
Telephone Number	:	801-495-1086

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	06/19/2008

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