Provider Demographics
NPI:1366656241
Name:PROHEALTH CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:PROHEALTH CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:FREDERIC
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-628-7040
Mailing Address - Street 1:523 E. SUNLAND DR.
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5799
Mailing Address - Country:US
Mailing Address - Phone:435-628-7040
Mailing Address - Fax:
Practice Address - Street 1:523 E. SUNLAND DR.
Practice Address - Street 2:SUITE C
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-5799
Practice Address - Country:US
Practice Address - Phone:435-628-7040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6366574-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000060492Medicare PIN