Healthcare Provider Details

I. General information

NPI: 1750374443
Provider Name (Legal Business Name): LIFE SKILLS NUTRITIONAL SUPPLEMENTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 12/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6912 S 185 W SUITE A
MIDVALE UT
84047-3719
US

IV. Provider business mailing address

15173 ROSE CANYON RD
HERRIMAN UT
84065-4482
US

V. Phone/Fax

Practice location:
  • Phone: 801-554-1830
  • Fax: 801-858-2626
Mailing address:
  • Phone: 801-554-1830
  • Fax: 801-858-2626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number20021545
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. ANGIE JEANIE DOHERTY
Title or Position: MANAGER
Credential:
Phone: 801-554-1830