Provider Demographics
NPI:1790087559
Name:CACHE VALLEY MEDICAL AND WELLNESS
Entity Type:Organization
Organization Name:CACHE VALLEY MEDICAL AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BENITA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:QUAKENBUSH-ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:435-755-0434
Mailing Address - Street 1:PO BOX 3443
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84323-3443
Mailing Address - Country:US
Mailing Address - Phone:435-755-0434
Mailing Address - Fax:
Practice Address - Street 1:196 S 100 W
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5233
Practice Address - Country:US
Practice Address - Phone:435-755-0434
Practice Address - Fax:435-755-0439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center