1124242128 NPI number — CARESOURCE

Table of content: (NPI 1124242128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124242128 NPI number — CARESOURCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARESOURCE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CARESOURCE SENIOR SUPPORTIVE CARE CENTER
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124242128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1624 E 4500 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84117-4212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-266-7200
Provider Business Mailing Address Fax Number:
801-266-7004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1624 E 4500 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84117-4212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-266-7200
Provider Business Practice Location Address Fax Number:
801-266-7004
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TANNER
Authorized Official First Name:
SHAWNTEL
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
801-266-7200

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  5221090-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207QH0002X , with the licence number: 5221090-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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