Healthcare Provider Details

I. General information

NPI: 1114897345
Provider Name (Legal Business Name): WASATCH G O D MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 S MAIN ST STE 108
SOUTH SALT LAKE UT
84115-5002
US

IV. Provider business mailing address

2480 S MAIN ST STE 108
SOUTH SALT LAKE UT
84115-5002
US

V. Phone/Fax

Practice location:
  • Phone: 385-612-1794
  • Fax:
Mailing address:
  • Phone: 385-612-1794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: TYREE KNIGHT
Title or Position: MANAGER
Credential:
Phone: 385-612-1794