Provider Demographics
NPI:1093245003
Name:PARK CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:PARK CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-292-2299
Mailing Address - Street 1:224 S MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-2206
Mailing Address - Country:US
Mailing Address - Phone:801-292-2299
Mailing Address - Fax:801-295-5835
Practice Address - Street 1:224 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-2206
Practice Address - Country:US
Practice Address - Phone:801-292-2299
Practice Address - Fax:801-295-5835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT174995-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty