Provider Demographics
NPI:1982928545
Name:INTEGRATED WELLCARE, LLC.
Entity Type:Organization
Organization Name:INTEGRATED WELLCARE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMISON
Authorized Official - Middle Name:
Authorized Official - Last Name:SIVULICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-358-7567
Mailing Address - Street 1:5168 CRUS CORVI RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-5336
Mailing Address - Country:US
Mailing Address - Phone:801-358-7567
Mailing Address - Fax:
Practice Address - Street 1:5168 CRUS CORVI RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84081-5336
Practice Address - Country:US
Practice Address - Phone:801-358-7567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty