Healthcare Provider Details

I. General information

NPI: 1629651013
Provider Name (Legal Business Name): EXTEND YOUR OHANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4892 S TEAL RIVER WAY
MURRAY UT
84123-4362
US

IV. Provider business mailing address

4892 S TEAL RIVER WAY
MURRAY UT
84123-4362
US

V. Phone/Fax

Practice location:
  • Phone: 801-879-6058
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name: KATJA TOLO
Title or Position: MANAGER
Credential:
Phone: 801-879-6058