NPIMap

Organization Active NPI

Life Integrative Health Center

  • Clinic/Center
  • Provo, UT
National Provider Identifier
1063833721
Registry record updated Apr 9, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
LIFE INTEGRATIVE HEALTH CENTER
Practice address
777 N 500 W
Suite 104
Provo, UT 84601-1541
Phone
(801) 869-8199
Fax
(801) 705-0436
NPI assigned
Dec 26, 2013
Last updated
Apr 9, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 9, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Kendra Bernal, MA
Title
Clinical Administrator
Phone
(801) 869-8199

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X Primary
Health Service Clinic/Center 261QH0100X NOT REQUIRED UT
Health Service Clinic/Center 261QH0100X 0000000 UT
Adult Mental Health Clinic/Center 261QM0850X NOT REQUIRED UT
Adult Mental Health Clinic/Center 261QM0850X 00000000000 UT
Adolescent and Children Mental Health Clinic/Center 261QM0855X NOT REQUIRED UT

Addresses

Primary practice location

777 N 500 W
Suite 104
Provo, UT 84601-1541

Mailing address

777 N 500 W Ste 104
Provo, UT 84601-1541
Phone (801) 869-8199

Other names 1

  • Theta Wellness Center - Provo Former legal business name

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1388016000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1397001600000",
    "number": "1063833721",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "777 N 500 W STE 104",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846011541",
            "telephone_number": "801-869-8199",
            "fax_number": "801-705-0436"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "777 N 500 W",
            "address_2": "SUITE 104",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846011541",
            "telephone_number": "801-869-8199",
            "fax_number": "801-705-0436"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFE INTEGRATIVE HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-12-26",
        "last_updated": "2014-04-09",
        "status": "A",
        "authorized_official_last_name": "BERNAL",
        "authorized_official_first_name": "KENDRA",
        "authorized_official_title_or_position": "CLINICAL ADMINISTRATOR",
        "authorized_official_telephone_number": "801-869-8199",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "MA"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": "UT",
            "license": "NOT REQUIRED",
            "primary": false
        },
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": "UT",
            "license": "0000000",
            "primary": false
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": "UT",
            "license": "NOT REQUIRED",
            "primary": false
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": "UT",
            "license": "00000000000",
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": "UT",
            "license": "NOT REQUIRED",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Theta Wellness Center - Provo",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Provo, UT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 9, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.