Provider Demographics
NPI:1346263100
Name:WALL, BRENT N (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:N
Last Name:WALL
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 1:205 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1726
Mailing Address - Country:US
Mailing Address - Phone:801-798-2515
Mailing Address - Fax:801-798-2510
Practice Address - Street 1:205 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1726
Practice Address - Country:US
Practice Address - Phone:801-798-2515
Practice Address - Fax:801-798-2510
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6089352-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor