Provider Demographics
NPI:1972024586
Name:BLENDTEC HEALTH CENTER
Entity Type:Organization
Organization Name:BLENDTEC HEALTH CENTER
Other - Org Name:BLENDTEC HEALTH AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LATSIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-225-1281
Mailing Address - Street 1:560 S 300 E STE 275
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3586
Mailing Address - Country:US
Mailing Address - Phone:801-441-1002
Mailing Address - Fax:
Practice Address - Street 1:1206 S 1680 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-4938
Practice Address - Country:US
Practice Address - Phone:801-225-1281
Practice Address - Fax:801-225-1282
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ONSITE CARE CLINICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10332017-1725207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty