Provider Demographics
NPI:1356155998
Name:FLY WHEEL CENTER UT LLC
Entity type:Organization
Organization Name:FLY WHEEL CENTER UT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHRAGA
Authorized Official - Middle Name:F
Authorized Official - Last Name:WAXMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-661-6533
Mailing Address - Street 1:174 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4054
Mailing Address - Country:US
Mailing Address - Phone:347-661-6533
Mailing Address - Fax:
Practice Address - Street 1:3564 RIDGELINE DR
Practice Address - Street 2:#14A
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098
Practice Address - Country:US
Practice Address - Phone:347-524-8681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty