Provider Demographics
NPI:1720447766
Name:UTAH WEIGHT LOSS, LLC
Entity Type:Organization
Organization Name:UTAH WEIGHT LOSS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-374-9625
Mailing Address - Street 1:3550 N UNIVERSITY AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6685
Mailing Address - Country:US
Mailing Address - Phone:801-374-9625
Mailing Address - Fax:801-374-9690
Practice Address - Street 1:1055 N 300 W STE 302
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3373
Practice Address - Country:US
Practice Address - Phone:801-852-3468
Practice Address - Fax:801-852-3459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT283029-1205132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Single Specialty