Provider Demographics
NPI:1063013886
Name:BRC WELLNESS LLC
Entity Type:Organization
Organization Name:BRC WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-652-7339
Mailing Address - Street 1:1265 E FORT UNION BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1904
Mailing Address - Country:US
Mailing Address - Phone:801-849-0453
Mailing Address - Fax:801-838-2100
Practice Address - Street 1:4911 S 900 E STE B
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5747
Practice Address - Country:US
Practice Address - Phone:801-676-9322
Practice Address - Fax:801-838-2100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility