MEDICARE: LEGACY HEALTHCARE OF LAYTON LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134442825
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY HEALTHCARE OF LAYTON LLC

Provider Business Mailing Address
First Line	:	1203 N FAIRFIELD RD
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-8321
Country	:	US
Telephone Number	:	801-927-5927
Fax Number	:	801-927-6235

Provider Business Practice Location Address
First Line	:	1203 N FAIRFIELD RD
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-8321
Country	:	US
Telephone Number	:	801-927-5927
Fax Number	:	801-927-6235

Authorized Official
Title or Position	:	OWNER
Name	:	PAUL FAIRHOLM
Credential	:
Telephone Number	:	801-269-0700

Provider Enumeration Date	:	03/09/2010
Last Update Date	:	07/11/2012

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