1013958479 NPI number — WORKSITE WELLNESS

Table of content: (NPI 1013958479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013958479 NPI number — WORKSITE WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WORKSITE WELLNESS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013958479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
249 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH SALT LAKE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84054-2438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-599-6412
Provider Business Mailing Address Fax Number:
801-964-2435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2520 W 4700 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAYLORSVILLE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84118-1847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-599-6412
Provider Business Practice Location Address Fax Number:
801-964-2435
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
DELOYQ
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
801-599-6412

Provider Taxonomy Codes

  • Taxonomy code: 2251N0400X , with the licence number:  4734414-2401 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 518960747001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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