MEDICARE: SSSHT OPCO 4522 S 1300 E 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1588163869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SSSHT OPCO 4522 S 1300 E LLC

Provider Business Mailing Address
First Line	:	4 PARK PLZ STE 400
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-2507
Country	:	US
Telephone Number	:	949-242-1417
Fax Number	:

Provider Business Practice Location Address
First Line	:	4522 S 1300 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4177
Country	:	US
Telephone Number	:	801-281-3477
Fax Number	:

Authorized Official
Title or Position	:	CONTROLLER MSL
Name	:	CHRISTIN KELLY
Credential	:	MSL COMMUNITY MANAGE
Telephone Number	:	949-242-1417

Provider Enumeration Date	:	02/01/2018
Last Update Date	:	02/01/2018

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