Provider Demographics
NPI:1912401613
Name:AMBROSE HEALTHCARE LLC
Entity Type:Organization
Organization Name:AMBROSE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-360-7668
Mailing Address - Street 1:920 HERITAGE PARK BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 HERITAGE PARK BLVD STE 120
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5609
Practice Address - Country:US
Practice Address - Phone:801-335-6455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2018-HHA-UT000840251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2018-HHA-UT000840OtherSTATE LICENSE NUMBER