MEDICARE: BALANCED EARTH WELLNESS LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1457087157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCED EARTH WELLNESS LLC

Provider Business Mailing Address
First Line	:	PO BOX 162
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84084-0162
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6995 S TOURIST LN APT 12
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84081-3737
Country	:	US
Telephone Number	:	801-577-0461
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JULIO JARVIS
Credential	:	LCSW
Telephone Number	:	801-577-0461

Provider Enumeration Date	:	07/26/2022
Last Update Date	:	01/12/2023

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