Provider Demographics
NPI:1275621922
Name:LUNDSTROM, CHAD A (DC)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:A
Last Name:LUNDSTROM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6244 VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-6156
Mailing Address - Country:US
Mailing Address - Phone:435-615-6684
Mailing Address - Fax:
Practice Address - Street 1:1790 SUN PEAK DR
Practice Address - Street 2:STE. A-201
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-6559
Practice Address - Country:US
Practice Address - Phone:435-649-4424
Practice Address - Fax:435-649-3278
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT313921-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000056205Medicare ID - Type Unspecified