Provider Demographics
NPI:1164673331
Name:EMPOWERED FOR LIFE, LLC
Entity Type:Organization
Organization Name:EMPOWERED FOR LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-244-6599
Mailing Address - Street 1:1467 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-2116
Mailing Address - Country:US
Mailing Address - Phone:801-244-6599
Mailing Address - Fax:801-969-7105
Practice Address - Street 1:5004 WEST JANETTE DRIVE
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120
Practice Address - Country:US
Practice Address - Phone:801-244-6599
Practice Address - Fax:801-969-7105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20071054320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities