Provider Demographics
NPI:1871829283
Name:LIFE STONE GROUP, LLC
Entity Type:Organization
Organization Name:LIFE STONE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-984-1717
Mailing Address - Street 1:613 E FORT UNION BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-5531
Mailing Address - Country:US
Mailing Address - Phone:801-984-1717
Mailing Address - Fax:801-984-1720
Practice Address - Street 1:613 E FORT UNION BLVD STE 104
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047
Practice Address - Country:US
Practice Address - Phone:801-984-1717
Practice Address - Fax:801-984-1720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
UT15893261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder