Healthcare Provider Details

I. General information

NPI: 1124242128
Provider Name (Legal Business Name): CARESOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 E 4500 S
SALT LAKE CITY UT
84117-4212
US

IV. Provider business mailing address

1624 E 4500 S
SALT LAKE CITY UT
84117-4212
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-7200
  • Fax: 801-266-7004
Mailing address:
  • Phone: 801-266-7200
  • Fax: 801-266-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5221090-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number5221090-1205
License Number StateUT

VIII. Authorized Official

Name: MRS. SHAWNTEL TANNER
Title or Position: ADMINISTRATOR
Credential: MA
Phone: 801-266-7200