Provider Demographics
NPI:1770188195
Name:KEYSTONE RESIDENTIAL CARE, LLC
Entity Type:Organization
Organization Name:KEYSTONE RESIDENTIAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MOANA
Authorized Official - Middle Name:OLIVIA
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-949-8509
Mailing Address - Street 1:6062 S HIDDEN PL
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-7676
Mailing Address - Country:US
Mailing Address - Phone:801-949-8509
Mailing Address - Fax:
Practice Address - Street 1:6062 S HIDDEN PL
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-7676
Practice Address - Country:US
Practice Address - Phone:801-949-8509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency