Provider Demographics
NPI:1700881505
Name:LIFE CARE AT HOME OF UTAH, INC.
Entity Type:Organization
Organization Name:LIFE CARE AT HOME OF UTAH, INC.
Other - Org Name:AFFINITY HOSPICE OF LIFE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-473-5280
Mailing Address - Street 1:3001 KEITH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3713
Mailing Address - Country:US
Mailing Address - Phone:423-473-5280
Mailing Address - Fax:423-339-8369
Practice Address - Street 1:2200 WEST PARKWAY BLVD
Practice Address - Street 2:STE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-2099
Practice Address - Country:US
Practice Address - Phone:801-973-0217
Practice Address - Fax:801-973-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-HOSPICE-66167251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505837Medicaid
NV100509587Medicaid
NV100509587Medicaid
UT461527Medicare Oscar/Certification