MEDICARE: HENNEFER'S HOME FOR THE ELDERLY

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	310400000X	Assisted Living Facility	2010-ALI-364	UT

General Provider Information

NPI Number	:	1205131091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HENNEFER'S HOME FOR THE ELDERLY

Provider Business Mailing Address
First Line	:	1200 E 4500 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4127
Country	:	US
Telephone Number	:	801-265-9617
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 E 4500 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4127
Country	:	US
Telephone Number	:	801-265-9617
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MS. MYRNA JEAN HENNEFER
Credential	:
Telephone Number	:	801-265-9617

Provider Enumeration Date	:	01/25/2011
Last Update Date	:	01/25/2011

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