Provider Demographics
NPI:1669257556
Name:WASATCH BEHAVIORAL HEALTH SPECIAL SERVICE DISTRICT
Entity type:Organization
Organization Name:WASATCH BEHAVIORAL HEALTH SPECIAL SERVICE DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUERGEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KORBANKA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-852-4703
Mailing Address - Street 1:750 N FREEDOM BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1690
Mailing Address - Country:US
Mailing Address - Phone:801-374-4760
Mailing Address - Fax:801-373-0639
Practice Address - Street 1:151 S UNIVERSITY AVE STE 1200
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4427
Practice Address - Country:US
Practice Address - Phone:385-268-5041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WASATCH BEHAVIORAL HEALTH SPECIAL SERVICE DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-29
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory