MEDICARE: LIFESKILLS VOCATIONAL CENTER

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	251C00000X	Developmentally Disabled Services Day Training Agency	19967974	UT

General Provider Information

NPI Number	:	1962492504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESKILLS VOCATIONAL CENTER

Provider Business Mailing Address
First Line	:	15173 ROSE CANYON RD
Second Line	:
City	:	HERRIMAN
State	:	UT
Zip	:	84065-4482
Country	:	US
Telephone Number	:	801-554-6992
Fax Number	:	801-977-3751

Provider Business Practice Location Address
First Line	:	1656 W 1500 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104
Country	:	US
Telephone Number	:	801-977-3732
Fax Number	:	801-977-3751

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. JEANIE PETTIT
Credential	:	ADMINISTRATOR CEO
Telephone Number	:	801-554-6992

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	08/22/2020

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