Healthcare Provider Details

I. General information

NPI: 1205645843
Provider Name (Legal Business Name): MR. MARK WEISENBURGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4785 W VISTA DR
HIGHLAND UT
84003-9585
US

IV. Provider business mailing address

4785 W VISTA DR
HIGHLAND UT
84003-9585
US

V. Phone/Fax

Practice location:
  • Phone: 801-358-6106
  • Fax:
Mailing address:
  • Phone: 801-358-6106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: