Healthcare Provider Details

I. General information

NPI: 1114446168
Provider Name (Legal Business Name): CANCER SURVIVOR HEALTH NETWORK, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2486 EAST EMERSON AVENUE
SALT LAKE CITY UT
84108
US

IV. Provider business mailing address

1338 S FOOTHILL DR # 333
SALT LAKE CITY UT
84108-2321
US

V. Phone/Fax

Practice location:
  • Phone: 801-754-6051
  • Fax: 801-210-0476
Mailing address:
  • Phone: 801-754-6051
  • Fax: 801-210-0476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code364SX0200X
TaxonomyOncology Clinical Nurse Specialist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL
# 8
Primary TaxonomyY
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number StateNULL

VIII. Authorized Official

Name: GEORGE WILLOCK
Title or Position: CEO
Credential:
Phone: 801-754-6051