Healthcare Provider Details

I. General information

NPI: 1366017667
Provider Name (Legal Business Name): UTAH BODY & SOUL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6440 S WASATCH BLVD STE 320
HOLLADAY UT
84121-3537
US

IV. Provider business mailing address

6440 S WASATCH BLVD STE 320
HOLLADAY UT
84121-3537
US

V. Phone/Fax

Practice location:
  • Phone: 801-987-8786
  • Fax:
Mailing address:
  • Phone: 801-987-8786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name: DEANNE LONG
Title or Position: OWNER
Credential: MD
Phone: 801-987-8786