Provider Demographics
NPI:1366632200
Name:CASCADE CHIROPRACTIC AND ACCIDENT REHABILITATION LLC
Entity Type:Organization
Organization Name:CASCADE CHIROPRACTIC AND ACCIDENT REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:1801-967-0825
Mailing Address - Street 1:3123 W 5400 S
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84118-2271
Mailing Address - Country:US
Mailing Address - Phone:180-196-7082
Mailing Address - Fax:
Practice Address - Street 1:3123 W 5400 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84118-2271
Practice Address - Country:US
Practice Address - Phone:180-196-7082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6562898-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty