Provider Demographics
NPI:1063833721
Name:LIFE INTEGRATIVE HEALTH CENTER
Entity Type:Organization
Organization Name:LIFE INTEGRATIVE HEALTH CENTER
Other - Org Name:THETA WELLNESS CENTER - PROVO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:801-869-8199
Mailing Address - Street 1:777 N 500 W STE 104
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1541
Mailing Address - Country:US
Mailing Address - Phone:801-869-8199
Mailing Address - Fax:801-705-0436
Practice Address - Street 1:777 N 500 W
Practice Address - Street 2:SUITE 104
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1541
Practice Address - Country:US
Practice Address - Phone:801-869-8199
Practice Address - Fax:801-705-0436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-26
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
UTNOT REQUIRED261QH0100X, 261QM0850X, 261QM0855X
UT0000000261QH0100X
UT00000000000261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health