Provider Demographics
NPI:1033341045
Name:WDC LLC
Entity Type:Organization
Organization Name:WDC LLC
Other - Org Name:CPT CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISTOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-636-8970
Mailing Address - Street 1:PO BOX 1504
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-1504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98 N WEST STATE RD
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-1486
Practice Address - Country:US
Practice Address - Phone:877-292-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-10
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center