Provider Demographics
NPI:1013958479
Name:WORKSITE WELLNESS
Entity type:Organization
Organization Name:WORKSITE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:DELOYQ
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:801-599-6412
Mailing Address - Street 1:249 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-2438
Mailing Address - Country:US
Mailing Address - Phone:801-599-6412
Mailing Address - Fax:801-964-2435
Practice Address - Street 1:2520 W 4700 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84118-1847
Practice Address - Country:US
Practice Address - Phone:801-599-6412
Practice Address - Fax:801-964-2435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4734414-24012251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT518960747001Medicaid