Provider Demographics
NPI:1043374911
Name:ALLEN, TOM (DC)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:ALLEN
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 1:72 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2144
Mailing Address - Country:US
Mailing Address - Phone:801-653-2900
Mailing Address - Fax:801-653-2910
Practice Address - Street 1:72 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2144
Practice Address - Country:US
Practice Address - Phone:801-653-2900
Practice Address - Fax:801-653-2910
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28616111N00000X
UT7201080-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7201080-1202OtherCHIROPRACTOR
CADC28616OtherCHIROPRACTIC LICENSE