Healthcare Provider Details

I. General information

NPI: 1093729048
Provider Name (Legal Business Name): NUTCRACKER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 WEST HWY 198
SALEM UT
84653-0786
US

IV. Provider business mailing address

PO BOX 786
SALEM UT
84653-0786
US

V. Phone/Fax

Practice location:
  • Phone: 801-423-3267
  • Fax: 801-423-3276
Mailing address:
  • Phone: 801-423-3267
  • Fax: 801-423-3276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1460511205
License Number StateUT

VIII. Authorized Official

Name: PHIL WASHBURN
Title or Position: CLINICAL ADVISER
Credential: MD
Phone: 801-423-3267