Provider Demographics
NPI:1164586954
Name:GRAND COUNTY WELLNESS CENTER
Entity Type:Organization
Organization Name:GRAND COUNTY WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ANDREW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-259-4466
Mailing Address - Street 1:255 WILLIAMS WAY
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532
Mailing Address - Country:US
Mailing Address - Phone:435-259-4466
Mailing Address - Fax:435-259-4467
Practice Address - Street 1:255 WILLIAMS WAY
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2370
Practice Address - Country:US
Practice Address - Phone:435-259-4466
Practice Address - Fax:435-259-4467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5141202-1205OtherSTATE LICENSE NUMBER
UTBA7037799OtherDEA #
UTH53849Medicare UPIN