Provider Demographics
NPI:1568107068
Name:INTEGRATED FUNCTIONAL MEDICINE
Entity Type:Organization
Organization Name:INTEGRATED FUNCTIONAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:WERSLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-296-9355
Mailing Address - Street 1:163 S SR 112 HWY STE 107
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-5520
Mailing Address - Country:US
Mailing Address - Phone:435-248-0603
Mailing Address - Fax:
Practice Address - Street 1:163 S SR 112 HWY STE 107
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84029-5520
Practice Address - Country:US
Practice Address - Phone:435-248-0603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATED FUNCTIONAL MEDICINE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty