Provider Demographics
NPI:1114977105
Name:FRIES, TIFFANI TABISH (DC)
Entity Type:Individual
Prefix:DR
First Name:TIFFANI
Middle Name:TABISH
Last Name:FRIES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E 3300 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2522
Mailing Address - Country:US
Mailing Address - Phone:801-485-2580
Mailing Address - Fax:801-485-2587
Practice Address - Street 1:1200 E 3300 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2522
Practice Address - Country:US
Practice Address - Phone:801-485-2580
Practice Address - Fax:801-485-2587
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5005891-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$001Medicaid
UT00005-6301Medicare PIN
UT00005-6301Medicare UPIN