Healthcare Provider Details

I. General information

NPI: 1780451864
Provider Name (Legal Business Name): INTEGRATED FUNCTIONAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/07/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 E 5600 S STE 104
SALT LAKE CITY UT
84107-8140
US

IV. Provider business mailing address

151 E 5600 S STE 104
SALT LAKE CITY UT
84107-8140
US

V. Phone/Fax

Practice location:
  • Phone: 385-228-4758
  • Fax:
Mailing address:
  • Phone: 385-228-4758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KIRK WERSLAND
Title or Position: OWNER
Credential:
Phone: 801-296-8060