1063833721 NPI number — LIFE INTEGRATIVE HEALTH CENTER

Table of content: (NPI 1063833721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063833721 NPI number — LIFE INTEGRATIVE HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE INTEGRATIVE HEALTH CENTER
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:
THETA WELLNESS CENTER - PROVO
Provider Other Organization Name Type Code:
4
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:
1063833721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 N 500 W STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84601-1541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-869-8199
Provider Business Mailing Address Fax Number:
801-705-0436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 N 500 W
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84601-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-869-8199
Provider Business Practice Location Address Fax Number:
801-705-0436
Provider Enumeration Date:
12/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BERNAL
Authorized Official First Name:
KENDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL ADMINISTRATOR
Authorized Official Telephone Number:
801-869-8199

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QH0100X , with the licence number: NOT REQUIRED , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0100X , with the licence number: 0000000 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X , with the licence number: NOT REQUIRED , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X , with the licence number: 00000000000 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X , with the licence number: NOT REQUIRED , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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