MEDICARE: CANCER SURVIVOR HEALTH NETWORK, L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	174400000X	Specialist
2	174H00000X	Health Educator
3	251B00000X	Case Management Agency
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
5	261QP2300X	Primary Care Clinic/Center
6	261QX0200X	Oncology Clinic/Center
7	364SX0200X	Oncology Clinical Nurse Specialist
8	405300000X	Prevention Professional
9	2083C0008X	Clinical Informatics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

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

Provider Business Mailing Address
First Line	:	1338 S FOOTHILL DR # 333
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2321
Country	:	US
Telephone Number	:	801-754-6051
Fax Number	:	801-210-0476

Provider Business Practice Location Address
First Line	:	2486 EAST EMERSON AVENUE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108
Country	:	US
Telephone Number	:	801-754-6051
Fax Number	:	801-210-0476

Authorized Official
Title or Position	:	CEO
Name	:	GEORGE WILLOCK
Credential	:
Telephone Number	:	801-754-6051

Provider Enumeration Date	:	09/11/2017
Last Update Date	:	03/26/2025

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Directions to “CANCER SURVIVOR HEALTH NETWORK, L.L.C. ” Practice Location

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