Provider Demographics
NPI:1346288594
Name:ROCKY MOUNTAIN CLINIC OF CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN CLINIC OF CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:K
Authorized Official - Last Name:MICKELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:801-782-2947
Mailing Address - Street 1:2240 N HWY 89 STE D
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84404-2824
Mailing Address - Country:US
Mailing Address - Phone:801-782-2947
Mailing Address - Fax:
Practice Address - Street 1:2240 N HWY 89 STE D
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:UT
Practice Address - Zip Code:84404-2824
Practice Address - Country:US
Practice Address - Phone:801-782-2947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6099655-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000059038Medicare PIN