Provider Demographics
NPI:1164221974
Name:GRATEFUL DIRECT PRIMARY CARE PLLC
Entity type:Organization
Organization Name:GRATEFUL DIRECT PRIMARY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:WALSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-639-0644
Mailing Address - Street 1:8541 S REDWOOD RD STE B1
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9323
Mailing Address - Country:US
Mailing Address - Phone:801-706-0171
Mailing Address - Fax:
Practice Address - Street 1:8541 S REDWOOD RD STE B1
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9323
Practice Address - Country:US
Practice Address - Phone:801-706-0171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty