Provider Demographics
NPI:1043548555
Name:FOOTHILL CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:FOOTHILL CHIROPRACTIC, INC
Other - Org Name:INTEGRATED CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:804-262-8400
Mailing Address - Street 1:716 E 4500 S
Mailing Address - Street 2:STE. N 250
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3080
Mailing Address - Country:US
Mailing Address - Phone:801-262-8400
Mailing Address - Fax:801-262-5570
Practice Address - Street 1:716 E 4500 S
Practice Address - Street 2:STE. N 250
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3080
Practice Address - Country:US
Practice Address - Phone:801-262-8400
Practice Address - Fax:801-262-5570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT176215-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty