MEDICARE: CANCER WELLNESS HOUSE, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251S00000X	Community/Behavioral Health Agency
2	251V00000X	Voluntary or Charitable Agency
3	261Q00000X	Clinic/Center
4	261QC1500X	Community Health Clinic/Center
5	261QH0100X	Health Service Clinic/Center
6	261QM0850X	Adult Mental Health Clinic/Center
7	261QM0855X	Adolescent and Children Mental Health Clinic/Center
8	2083P0901X	Public Health & General Preventive Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01	OTHER		CLINIC/GROUP PRACTICE

General Provider Information

NPI Number	:	1467071407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANCER WELLNESS HOUSE, INC.

Provider Business Mailing Address
First Line	:	59 S 1100 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1508
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	59 S 1100 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1508
Country	:	US
Telephone Number	:	801-236-2294
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. JOHN LIBRETT
Credential	:	PHD, MPH
Telephone Number	:	801-558-5950

Provider Enumeration Date	:	04/09/2020
Last Update Date	:	04/09/2020

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Directions to “CANCER WELLNESS HOUSE, INC. ” Practice Location

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