Provider Demographics
NPI:1386129765
Name:ELEMENTS TRAVERSE LLC
Entity type:Organization
Organization Name:ELEMENTS TRAVERSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-558-0334
Mailing Address - Street 1:1768 E INDIAN WELLS LN
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8898
Mailing Address - Country:US
Mailing Address - Phone:801-558-0334
Mailing Address - Fax:
Practice Address - Street 1:130 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:UT
Practice Address - Zip Code:84528-5501
Practice Address - Country:US
Practice Address - Phone:801-558-0334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health