MEDICARE: JOHANNA CARE CENTER, INC.

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	314000000X	Skilled Nursing Facility	2006-NCF-58	UT

General Provider Information

NPI Number	:	1932204492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHANNA CARE CENTER, INC.

Provider Business Mailing Address
First Line	:	433 E 2700 S
Second Line	:
City	:	S SALT LAKE
State	:	UT
Zip	:	84115-3325
Country	:	US
Telephone Number	:	801-487-2248
Fax Number	:	801-746-8554

Provider Business Practice Location Address
First Line	:	433 E 2700 S
Second Line	:
City	:	S SALT LAKE
State	:	UT
Zip	:	84115-3325
Country	:	US
Telephone Number	:	801-487-2248
Fax Number	:	801-746-8554

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. WALTER MATJASICH
Credential	:
Telephone Number	:	801-487-2248

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	08/22/2020

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