Provider Demographics
NPI:1003088402
Name:PROVO SPORTS AND FAMILY CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:PROVO SPORTS AND FAMILY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-375-2420
Mailing Address - Street 1:777 N 500 W STE 205
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1596
Mailing Address - Country:US
Mailing Address - Phone:801-375-2420
Mailing Address - Fax:801-374-8588
Practice Address - Street 1:777 N 500 W STE 205
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1596
Practice Address - Country:US
Practice Address - Phone:801-375-2420
Practice Address - Fax:801-374-8588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT355063-1202111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU6911Medicare UPIN