Provider Demographics
NPI:1235353236
Name:CARESOURCE LLC
Entity Type:Organization
Organization Name:CARESOURCE LLC
Other - Org Name:CARESOURCE HOSPICE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWNTEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:801-266-7200
Mailing Address - Street 1:1624 E 4500 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4212
Mailing Address - Country:US
Mailing Address - Phone:801-266-7200
Mailing Address - Fax:801-266-7004
Practice Address - Street 1:1624 E 4500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4212
Practice Address - Country:US
Practice Address - Phone:801-266-7200
Practice Address - Fax:801-266-7004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-HOSPICE-30731251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========029Medicaid
UT=========029Medicaid