Healthcare Provider Details

I. General information

NPI: 1063833721
Provider Name (Legal Business Name): LIFE INTEGRATIVE HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2013
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N 500 W SUITE 104
PROVO UT
84601-1541
US

IV. Provider business mailing address

777 N 500 W STE 104
PROVO UT
84601-1541
US

V. Phone/Fax

Practice location:
  • Phone: 801-869-8199
  • Fax: 801-705-0436
Mailing address:
  • Phone: 801-869-8199
  • Fax: 801-705-0436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberNOT REQUIRED
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number0000000
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberNOT REQUIRED
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number00000000000
License Number StateUT
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberNOT REQUIRED
License Number StateUT

VIII. Authorized Official

Name: MRS. KENDRA BERNAL
Title or Position: CLINICAL ADMINISTRATOR
Credential: MA
Phone: 801-869-8199