Provider Demographics
NPI:1750374443
Name:LIFE SKILLS NUTRITIONAL SUPPLEMENTS
Entity type:Organization
Organization Name:LIFE SKILLS NUTRITIONAL SUPPLEMENTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:JEANIE
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-554-1830
Mailing Address - Street 1:15173 ROSE CANYON RD
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84065-4482
Mailing Address - Country:US
Mailing Address - Phone:801-554-1830
Mailing Address - Fax:801-858-2626
Practice Address - Street 1:6912 S 185 W
Practice Address - Street 2:SUITE A
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-3719
Practice Address - Country:US
Practice Address - Phone:801-554-1830
Practice Address - Fax:801-858-2626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20021545332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT4588300001Medicare NSC