Provider Demographics
NPI:1043485188
Name:MT. OLYMPUS CLINIC OF CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:MT. OLYMPUS CLINIC OF CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:HADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-268-4993
Mailing Address - Street 1:715 E 3900 S
Mailing Address - Street 2:SUITE 205-A
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2182
Mailing Address - Country:US
Mailing Address - Phone:801-268-4993
Mailing Address - Fax:801-268-4241
Practice Address - Street 1:715 E 3900 S
Practice Address - Street 2:SUITE 205-A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2182
Practice Address - Country:US
Practice Address - Phone:801-268-4993
Practice Address - Fax:801-268-4241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT57703761202261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health