MEDICARE: LIFE CARE AT HOME OF UTAH, INC.

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	251G00000X	Community Based Hospice Care Agency	2005-HOSPICE-66167	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700881505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE CARE AT HOME OF UTAH, INC.

Provider Business Mailing Address
First Line	:	3001 KEITH ST NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312-3713
Country	:	US
Telephone Number	:	423-473-5280
Fax Number	:	423-339-8369

Provider Business Practice Location Address
First Line	:	2200 WEST PARKWAY BLVD
Second Line	:	STE 200
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84119-2099
Country	:	US
Telephone Number	:	801-973-0217
Fax Number	:	801-973-0229

Authorized Official
Title or Position	:	VICE PRESIDENT FINANCE
Name	:	PAM RAU
Credential	:
Telephone Number	:	423-473-5280

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	01/24/2013

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