Provider Demographics
NPI:1275741001
Name:CHIROPRACTIC HEALTH AND REHAB, LLC
Entity Type:Organization
Organization Name:CHIROPRACTIC HEALTH AND REHAB, LLC
Other - Org Name:CHIROPRACTIC HEALTH AND REHAB
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:ARNOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-972-0393
Mailing Address - Street 1:1264 VILLAGE MAIN DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3396
Mailing Address - Country:US
Mailing Address - Phone:801-972-0393
Mailing Address - Fax:801-972-5707
Practice Address - Street 1:1264 VILLAGE MAIN DR
Practice Address - Street 2:SUITE A
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3396
Practice Address - Country:US
Practice Address - Phone:801-972-0393
Practice Address - Fax:801-972-5707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT55687841202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529792876001Medicaid
UT529792876001Medicaid
UTU99719Medicare UPIN