Healthcare Provider Details

I. General information

NPI: 1225648199
Provider Name (Legal Business Name): SOULEGRIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 S MAIN ST
HURRICANE UT
84737-1949
US

IV. Provider business mailing address

11 S MAIN ST
HURRICANE UT
84737-1949
US

V. Phone/Fax

Practice location:
  • Phone: 800-792-0435
  • Fax: 877-698-4968
Mailing address:
  • Phone: 800-792-0435
  • Fax: 877-698-4968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TYLER OLSEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 801-285-6100