Provider Demographics
NPI:1346549060
Name:KELLY WOSNIK INC
Entity Type:Organization
Organization Name:KELLY WOSNIK INC
Other - Org Name:BRISTOL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOSNIK
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:801-903-5903
Mailing Address - Street 1:935 S OREM BLVD
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5011
Mailing Address - Country:US
Mailing Address - Phone:801-903-5903
Mailing Address - Fax:801-515-0935
Practice Address - Street 1:1125 W CENTER ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-5207
Practice Address - Country:US
Practice Address - Phone:801-903-5903
Practice Address - Fax:801-515-0935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT327710-4405261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1010479Medicaid