Healthcare Provider Details

I. General information

NPI: 1376912089
Provider Name (Legal Business Name): EAST WEST HEALTH PARK CITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 SUN PEAK DR STE A102
PARK CITY UT
84098-6651
US

IV. Provider business mailing address

1790 SUN PEAK DR SUITE B106
PARK CITY UT
84098-6559
US

V. Phone/Fax

Practice location:
  • Phone: 435-640-1353
  • Fax:
Mailing address:
  • Phone: 435-640-1353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number5743144-1201
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4803531-1205
License Number StateUT

VIII. Authorized Official

Name: REGAN ARCHIBALD
Title or Position: PARTNER
Credential:
Phone: 435-640-1353