Healthcare Provider Details

I. General information

NPI: 1871829283
Provider Name (Legal Business Name): LIFE STONE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 E FORT UNION BLVD STE 104
MIDVALE UT
84047
US

IV. Provider business mailing address

613 E FORT UNION BLVD STE 104
MIDVALE UT
84047-5531
US

V. Phone/Fax

Practice location:
  • Phone: 801-984-1717
  • Fax: 801-984-1720
Mailing address:
  • Phone: 801-984-1717
  • Fax: 801-984-1720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number15893
License Number StateUT

VIII. Authorized Official

Name: MRS. JULIE A. PETTIT
Title or Position: OWNER/PARTNER
Credential:
Phone: 801-984-1717