MEDICARE: FAMILY CARE 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1356817167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY CARE LLC

Provider Business Mailing Address
First Line	:	2569 S BEAGLEY CIR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84128-5539
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2569 S BEAGLEY CIR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84128-5539
Country	:	US
Telephone Number	:	385-246-3996
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LEAAEPINE MATAELE
Credential	:
Telephone Number	:	801-644-1481

Provider Enumeration Date	:	10/18/2018
Last Update Date	:	10/18/2018

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