Healthcare Provider Details

I. General information

NPI: 1548469752
Provider Name (Legal Business Name): TRI-COUNTY INDEPENDENT LIVING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2726 WASHINGTON BLVD
OGDEN UT
84401-3677
US

IV. Provider business mailing address

2726 WASHINGTON BLVD
OGDEN UT
84401-3677
US

V. Phone/Fax

Practice location:
  • Phone: 801-612-3215
  • Fax: 801-612-3732
Mailing address:
  • Phone: 801-612-3215
  • Fax: 801-612-3732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number001
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number001
License Number StateUT

VIII. Authorized Official

Name: MRS. VICKIE CALL BRENCHLEY
Title or Position: DEPUTY DIRECTOR
Credential:
Phone: 801-612-3215