MEDICARE: OVERLAKE TERRACE ASSISTED LIVING

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	603224991	WA

General Provider Information

NPI Number	:	1912241001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OVERLAKE TERRACE ASSISTED LIVING

Provider Business Mailing Address
First Line	:	2825 E COTTONWOOD PKWY
Second Line	:	SUITE 500
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-7055
Country	:	US
Telephone Number	:	801-790-4652
Fax Number	:	801-214-1970

Provider Business Practice Location Address
First Line	:	2825 E COTTONWOOD PKWY
Second Line	:	SUITE 500
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-7055
Country	:	US
Telephone Number	:	801-790-4652
Fax Number	:	801-214-1970

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	AARON C BENTON
Credential	:
Telephone Number	:	801-790-4652

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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