Healthcare Provider Details

I. General information

NPI: 1164176731
Provider Name (Legal Business Name): INTEGRATED WELLNESS UTAH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 04/12/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 S 500 E STE 202
SLC UT
84102-1094
US

IV. Provider business mailing address

34 S 500 E STE 202
SLC UT
84102-1094
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-2011
  • Fax: 801-582-2011
Mailing address:
  • Phone: 801-582-2011
  • Fax: 801-582-2011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LAURA HILL
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 801-860-9404