MEDICARE: CHP LAYTON UT TENANT CORP.

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	311500000X	Alzheimer Center (Dementia Center)		UT
2	310400000X	Assisted Living Facility		UT

General Provider Information

NPI Number	:	1477958353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHP LAYTON UT TENANT CORP.

Provider Business Mailing Address
First Line	:	450 S ORANGE AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32801-3383
Country	:	US
Telephone Number	:	801-807-0111
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 N FAIRFIELD RD
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-8321
Country	:	US
Telephone Number	:	407-540-7652
Fax Number	:

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	KEVIN RAY MADDRON
Credential	:
Telephone Number	:	407-540-7519

Provider Enumeration Date	:	11/04/2014
Last Update Date	:	11/04/2014

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