Provider Demographics
NPI:1316490402
Name:CARESOURCE
Entity type:Organization
Organization Name:CARESOURCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNTEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, SSW
Authorized Official - Phone:801-266-7200
Mailing Address - Street 1:1624 E 4500 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4212
Mailing Address - Country:US
Mailing Address - Phone:801-266-7200
Mailing Address - Fax:801-266-7004
Practice Address - Street 1:1624 E 4500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4212
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:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2016-NCF-UT000747314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility