Provider Demographics
NPI:1043523814
Name:WHITTAKER CHIROPRACTIC CENTER, PC
Entity Type:Organization
Organization Name:WHITTAKER CHIROPRACTIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLYLE
Authorized Official - Middle Name:BRET
Authorized Official - Last Name:WHITTAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-896-5656
Mailing Address - Street 1:458 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-2846
Mailing Address - Country:US
Mailing Address - Phone:435-896-5656
Mailing Address - Fax:435-896-2842
Practice Address - Street 1:458 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-2846
Practice Address - Country:US
Practice Address - Phone:435-896-5656
Practice Address - Fax:435-896-2842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT172697-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528235261019Medicaid
000056035OtherMEDICARE PTAN
UT528235261019Medicaid