Healthcare Provider Details

I. General information

NPI: 1336718204
Provider Name (Legal Business Name): INTEGRATED TMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1664 S DIXIE DR STE 102 BLD E
SAINT GEORGE UT
84770-7327
US

IV. Provider business mailing address

1664 S DIXIE DR STE 102 BLD E
SAINT GEORGE UT
84770-7327
US

V. Phone/Fax

Practice location:
  • Phone: 435-767-8840
  • Fax: 435-703-6003
Mailing address:
  • Phone: 435-767-8840
  • Fax: 435-703-6003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: FORREST JIM WOLVERTON
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 435-767-8840