MEDICARE: CHATEAU BRICKYARD MANAGEMENT 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	:	1659624278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHATEAU BRICKYARD MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	1800 SW 1ST AVENUE
Second Line	:	# 180
City	:	PORTLAND
State	:	OR
Zip	:	97201-5362
Country	:	US
Telephone Number	:	503-684-1123
Fax Number	:	503-684-2533

Provider Business Practice Location Address
First Line	:	3080 S RICHMOND ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3000
Country	:	US
Telephone Number	:	801-466-9999
Fax Number	:	801-466-7650

Authorized Official
Title or Position	:	CEO, PRESIDENT & SECRETARY
Name	:	AMY ALLEN
Credential	:
Telephone Number	:	212-478-4117

Provider Enumeration Date	:	10/19/2012
Last Update Date	:	10/19/2012

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