Provider Demographics
NPI:1962748988
Name:LIBERTY HEALTH & WELLNESS LLC
Entity type:Organization
Organization Name:LIBERTY HEALTH & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-487-1010
Mailing Address - Street 1:1473 S 600 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2062
Mailing Address - Country:US
Mailing Address - Phone:801-487-1010
Mailing Address - Fax:801-487-1015
Practice Address - Street 1:1473 S 600 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2062
Practice Address - Country:US
Practice Address - Phone:801-487-1010
Practice Address - Fax:801-487-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT170061-1202261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center