Provider Demographics
NPI:1932656923
Name:CARESOURCE CHARITABLE ASSOCIATION
Entity Type:Organization
Organization Name:CARESOURCE CHARITABLE ASSOCIATION
Other - Org Name:CARESOURCE HOSPICE AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNTEL
Authorized Official - Middle Name:YATES
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CHPCA, SSW, PHR
Authorized Official - Phone:801-266-7200
Mailing Address - Street 1:750 KEARNS BLVD. #200
Mailing Address - Street 2:PO BOX 683593
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84068-3593
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:84060-5137
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:2016-09-07
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2016251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based