MEDICARE: BEEHIVE AT EAST MILLCREEK, 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	AL-105249	UT

General Provider Information

NPI Number	:	1629343082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEEHIVE AT EAST MILLCREEK, LLC

Provider Business Mailing Address
First Line	:	3681 S 2300 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-3418
Country	:	US
Telephone Number	:	801-272-2290
Fax Number	:

Provider Business Practice Location Address
First Line	:	3681 S 2300 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-3418
Country	:	US
Telephone Number	:	801-272-2290
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DALE T JOHNSON
Credential	:
Telephone Number	:	801-388-0565

Provider Enumeration Date	:	03/19/2012
Last Update Date	:	03/19/2012

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