Organization
LIFE ELEVATED FAMILY MEDICINE & COUNSELING LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BROCK DAN HASKELL (PA/OWNER)
(435) 830-0554
Entity
Organization
Contact information
Practice address
3686 W. 2100 S., SALT LAKE CITY, UT 84120-8412
(435) 830-0554
(385) 247-8023
Mailing address
2561 S 1560 W STE B, WOODS CROSS, UT 84087-2361
(801) 505-0821
(801) 505-0803
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
118561179-1206
LICENSE
UT
Enumeration date
10/01/2021
Last updated
10/01/2021
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