Provider Demographics
NPI:1407466089
Name:WASATCH BACK VENTURE TRAIL
Entity type:Organization
Organization Name:WASATCH BACK VENTURE TRAIL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-513-2715
Mailing Address - Street 1:3585 N UNIVERSITY AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6622
Mailing Address - Country:US
Mailing Address - Phone:435-513-2715
Mailing Address - Fax:
Practice Address - Street 1:3585 N UNIVERSITY AVE STE 250
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6622
Practice Address - Country:US
Practice Address - Phone:435-513-2715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty