Provider Demographics
NPI:1366114944
Name:LIFE ELEVATED FAMILY MEDICINE & COUNSELING LLC
Entity type:Organization
Organization Name:LIFE ELEVATED FAMILY MEDICINE & COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:DAN
Authorized Official - Last Name:HASKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-830-0554
Mailing Address - Street 1:2561 S 1560 W STE B
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-2361
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:801-505-0803
Practice Address - Street 1:3686 W. 2100 S.
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-8412
Practice Address - Country:US
Practice Address - Phone:435-830-0554
Practice Address - Fax:385-247-8023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT118561179-1206OtherLICENSE