Provider Demographics
NPI:1033507751
Name:KOWALLIS, CAMRON DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:CAMRON
Middle Name:DAVID
Last Name:KOWALLIS
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 1:806 E MAIN ST
Mailing Address - Street 2:UNIT F
Mailing Address - City:TREMONTON
Mailing Address - State:UT
Mailing Address - Zip Code:84337-6733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:806 E MAIN ST
Practice Address - Street 2:UNIT F
Practice Address - City:TREMONTON
Practice Address - State:UT
Practice Address - Zip Code:84337-6733
Practice Address - Country:US
Practice Address - Phone:801-472-3907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9182915-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor