Provider Demographics
NPI:1073805289
Name:SPINE AND MUSCULAR REHABILITATION CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:SPINE AND MUSCULAR REHABILITATION CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRENTON
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-351-8329
Mailing Address - Street 1:60 N CENTER ST
Mailing Address - Street 2:PO BOX 335
Mailing Address - City:WELLSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84339-9412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1634 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1920
Practice Address - Country:US
Practice Address - Phone:208-351-8329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7975292-1202261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service