Basic Information
| Provider Information | |||||||||
| NPI: | 1215595871 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFE HEALTH REGENERATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1770 E FORT UNION BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841212881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019978881 | ||||||||
| FaxNumber: | 8019445910 | ||||||||
| Practice Location | |||||||||
| Address1: | 1770 E FORT UNION BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841212881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019978881 | ||||||||
| FaxNumber: | 8019445910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2019 | ||||||||
| LastUpdateDate: | 05/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8014506940 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.