Healthcare Provider Details

I. General information

NPI: 1992423263
Provider Name (Legal Business Name): CLG BETA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 S 900 E SUITE 260
MURRAY UT
84117
US

IV. Provider business mailing address

5151 S 900 E SUITE 260
MURRAY UT
84117
US

V. Phone/Fax

Practice location:
  • Phone: 801-671-4357
  • Fax: 385-388-8305
Mailing address:
  • Phone: 801-671-4357
  • Fax: 385-388-8305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: LUDWIG AGURTO
Title or Position: HYPNOTHERAPIST
Credential:
Phone: 801-928-4111