Provider Demographics
NPI:1891436432
Name:SUMMIT WELLNESS INSTITUTE LLC
Entity Type:Organization
Organization Name:SUMMIT WELLNESS INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-345-3560
Mailing Address - Street 1:3000 N TRIUMPH BLVD STE 330
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4999
Mailing Address - Country:US
Mailing Address - Phone:385-345-3560
Mailing Address - Fax:877-331-0467
Practice Address - Street 1:3000 N TRIUMPH BLVD STE 330
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4999
Practice Address - Country:US
Practice Address - Phone:385-345-3560
Practice Address - Fax:877-331-0467
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT BRAIN AND SPINE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty