MEDICARE: AMBROSE HEALTHCARE 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	251E00000X	Home Health Agency	2018-HHA-UT000840

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2018-HHA-UT000840	OTHER	UT	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1912401613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMBROSE HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	920 HERITAGE PARK BLVD STE 120
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-5609
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 HERITAGE PARK BLVD STE 120
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-5609
Country	:	US
Telephone Number	:	801-335-6455
Fax Number	:

Authorized Official
Title or Position	:	VP OF BUSINESS DEVELOPMENT
Name	:	MR. TRAVIS COLLETTE
Credential	:
Telephone Number	:	208-360-7668

Provider Enumeration Date	:	03/19/2018
Last Update Date	:	03/19/2018

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Directions to “AMBROSE HEALTHCARE LLC ” Practice Location

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