Healthcare Provider Details

I. General information

NPI: 1982928545
Provider Name (Legal Business Name): INTEGRATED WELLCARE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5168 CRUS CORVI RD
WEST JORDAN UT
84081-5336
US

IV. Provider business mailing address

5168 CRUS CORVI RD
WEST JORDAN UT
84081-5336
US

V. Phone/Fax

Practice location:
  • Phone: 801-358-7567
  • Fax:
Mailing address:
  • Phone: 801-358-7567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMISON SIVULICH
Title or Position: MANAGING MEMBER
Credential:
Phone: 801-358-7567