Provider Demographics
NPI:1619286879
Name:UTAH WEIGHT LOSS & NATURAL HORMONE CLINIC
Entity Type:Organization
Organization Name:UTAH WEIGHT LOSS & NATURAL HORMONE CLINIC
Other - Org Name:UTAH WEIGHT LOSS & NATURAL HORMONE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DESANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:801-272-1246
Mailing Address - Street 1:1378 SW DAVID DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-6429
Mailing Address - Country:US
Mailing Address - Phone:801-272-1246
Mailing Address - Fax:
Practice Address - Street 1:1378 SW DAVID DR
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-6429
Practice Address - Country:US
Practice Address - Phone:801-272-1246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201603205NP-PP261QP2300X
UT275822-8900261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care