Provider Demographics
NPI:1174858823
Name:THERAPEUTIC WELLNESS CENTER
Entity Type:Organization
Organization Name:THERAPEUTIC WELLNESS CENTER
Other - Org Name:PARAGON HEALTHCARE OF UTAH, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-479-9644
Mailing Address - Street 1:5974 FASHION POINT DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4699
Mailing Address - Country:US
Mailing Address - Phone:801-479-9644
Mailing Address - Fax:801-479-9639
Practice Address - Street 1:5974 FASHION POINT DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4699
Practice Address - Country:US
Practice Address - Phone:801-479-9644
Practice Address - Fax:801-479-9639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-14
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7487072-0161261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000072054OtherMEDICARE PTAN