Provider Demographics
NPI:1356643001
Name:SPORTS CHIROPRACTIC AND WELLNESS CENTER PC
Entity Type:Organization
Organization Name:SPORTS CHIROPRACTIC AND WELLNESS CENTER PC
Other - Org Name:OPTIMAL WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:NIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-568-1598
Mailing Address - Street 1:193 E FORT UNION BLVD
Mailing Address - Street 2:203
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-5660
Mailing Address - Country:US
Mailing Address - Phone:801-568-1598
Mailing Address - Fax:801-568-1594
Practice Address - Street 1:193 E FORT UNION BLVD
Practice Address - Street 2:203
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-5660
Practice Address - Country:US
Practice Address - Phone:801-568-1598
Practice Address - Fax:801-568-1594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT365045-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty