Healthcare Provider Details

I. General information

NPI: 1063658284
Provider Name (Legal Business Name): GEORGE E WAHLEN VA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 03/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA SLC HCS 500 FOOTHILL BLVD
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

VA SLC HCS 500 FOOTHILL BLVD
SALT LAKE CITY UT
84148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax: 801-584-2576
Mailing address:
  • Phone: 801-582-1565
  • Fax: 801-584-2576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number2085793102
License Number StateUT

VIII. Authorized Official

Name: JANMARIE PETERSEN
Title or Position: STAFF NURSE
Credential: RN, CDE
Phone: 801-582-1565