MEDICARE: LUCKY IYE

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	374U00000X	Home Health Aide	9710753-0151	UT

General Provider Information

NPI Number	:	1881055168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCKY IYE

Provider Business Mailing Address
First Line	:	175 S MAIN ST STE 500
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1927
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 S MAIN ST STE 500
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1927
Country	:	US
Telephone Number	:	801-856-3174
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2016
Last Update Date	:	03/14/2016

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Directions to “ LUCKY IYE ” Practice Location

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