Provider Demographics
NPI:1467071407
Name:CANCER WELLNESS HOUSE, INC.
Entity Type:Organization
Organization Name:CANCER WELLNESS HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIBRETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MPH
Authorized Official - Phone:801-558-5950
Mailing Address - Street 1:59 S 1100 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:59 S 1100 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1508
Practice Address - Country:US
Practice Address - Phone:801-236-2294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No251V00000XAgenciesVoluntary or Charitable
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01OtherCLINIC/GROUP PRACTICE