Provider Demographics
NPI:1508619040
Name:WASATCH OPTIMAL WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:WASATCH OPTIMAL WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR / COO
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-712-2535
Mailing Address - Street 1:1716 N HIGHWAY 40 STE 200
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-4677
Mailing Address - Country:US
Mailing Address - Phone:435-800-6969
Mailing Address - Fax:
Practice Address - Street 1:1716 N HIGHWAY 40 STE 200
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-4677
Practice Address - Country:US
Practice Address - Phone:435-800-6969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service