Provider Demographics
NPI:1376136457
Name:WELLNESS BRIDGE GROUP
Entity Type:Organization
Organization Name:WELLNESS BRIDGE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JARRED
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BA (HONS) BUSINESS
Authorized Official - Phone:385-685-8566
Mailing Address - Street 1:752 S WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:UT
Mailing Address - Zip Code:84664-5618
Mailing Address - Country:US
Mailing Address - Phone:385-685-8566
Mailing Address - Fax:
Practice Address - Street 1:994 EXPRESSWAY LN
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1384
Practice Address - Country:US
Practice Address - Phone:385-685-8566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization