Provider Demographics
NPI:1902861693
Name:CARESOURCE
Entity Type:Organization
Organization Name:CARESOURCE
Other - Org Name:CARESOURCE HOME HEALTH AND HOSPICE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWNTEL
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:801-266-7200
Mailing Address - Street 1:PO BOX 680839
Mailing Address - Street 2:750 KEARNS BLVD. #200
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84068
Mailing Address - Country:US
Mailing Address - Phone:801-266-7200
Mailing Address - Fax:801-266-7004
Practice Address - Street 1:750 KEARNS BLVD. #200
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060
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:2006-04-18
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-HHA-912251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTHT005376-001OtherTRADING PARTNER NUMBER
UTHT005376-001OtherTRADING PARTNER NUMBER
UT467117Medicare ID - Type UnspecifiedHOME CARE MEDICARE PROVID