MEDICARE: MG TAYLORSVILLE SUBTENANT 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	:	1255969291
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MG TAYLORSVILLE SUBTENANT LLC

Provider Business Mailing Address
First Line	:	1938 FAIRVIEW AVE E STE 300
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98102-3650
Country	:	US
Telephone Number	:	206-676-5300
Fax Number	:	206-676-5353

Provider Business Practice Location Address
First Line	:	2011 W 4700 S
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84129-1107
Country	:	US
Telephone Number	:	801-966-4286
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	DOUGLAS D. SPEAR
Credential	:
Telephone Number	:	206-676-5300

Provider Enumeration Date	:	03/27/2020
Last Update Date	:	05/25/2021

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