| NPI | 1134465909 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GREG CARL NICKLES Owner/Clinical Director 801-979-1351 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X (Licence: UT 304614-6004) |
| Enumeration Date | 2012-12-22 |
| Last Update Date | 2012-12-22 |