Provider Demographics
NPI:1487427340
Name:NUTRIX UTAH PC
Entity type:Organization
Organization Name:NUTRIX UTAH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:AGPCNP-BC, PMHNP
Authorized Official - Phone:801-425-2831
Mailing Address - Street 1:6621 W WIDE HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-3550
Mailing Address - Country:US
Mailing Address - Phone:801-425-2831
Mailing Address - Fax:
Practice Address - Street 1:6621 W WIDE HOLLOW DR
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-3550
Practice Address - Country:US
Practice Address - Phone:801-425-2831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-02
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty