MEDICARE: COUNTRY NICHE ADULT DAY CARE

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	385H00000X	Respite Care

General Provider Information

NPI Number	:	1780067785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTRY NICHE ADULT DAY CARE

Provider Business Mailing Address
First Line	:	PO BOX 150493
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84415-0493
Country	:	US
Telephone Number	:	801-436-5727
Fax Number	:

Provider Business Practice Location Address
First Line	:	2179 W 1800 N STE D
Second Line	:
City	:	CLINTON
State	:	UT
Zip	:	84015-7900
Country	:	US
Telephone Number	:	801-436-5727
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JENNIE FRY
Credential	:
Telephone Number	:	801-436-5727

Provider Enumeration Date	:	07/08/2015
Last Update Date	:	07/08/2015

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Directions to “COUNTRY NICHE ADULT DAY CARE ” Practice Location

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