Provider Demographics
NPI:1003055534
Name:LUNDAHL, BRIGHAM (DC)
Entity Type:Individual
Prefix:
First Name:BRIGHAM
Middle Name:
Last Name:LUNDAHL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 W SAINT GEORGE BLVD
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3352
Mailing Address - Country:US
Mailing Address - Phone:435-272-7554
Mailing Address - Fax:435-674-0399
Practice Address - Street 1:358 W SAINT GEORGE BLVD
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3352
Practice Address - Country:US
Practice Address - Phone:435-628-3438
Practice Address - Fax:435-674-0399
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6763842-1202111NS0005X, 111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000075270Medicare UPIN