MEDICARE: PHEASANT VIEW ASSISTED LIVING, 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	2011-ALII-99476	UT

General Provider Information

NPI Number	:	1639468507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHEASANT VIEW ASSISTED LIVING, LLC

Provider Business Mailing Address
First Line	:	1242 E PHEASANT VIEW DRIVE
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-7423
Country	:	US
Telephone Number	:	801-546-4100
Fax Number	:	801-927-1036

Provider Business Practice Location Address
First Line	:	1242 E PHEASANT VIEW DRIVE
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-7423
Country	:	US
Telephone Number	:	801-546-4100
Fax Number	:	801-927-1036

Authorized Official
Title or Position	:	DIRECTOR, MANAGING MEMBER
Name	:	ERIC C MARTZ
Credential	:
Telephone Number	:	801-546-4100

Provider Enumeration Date	:	03/31/2011
Last Update Date	:	03/31/2011

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