Provider Demographics
NPI:1386859817
Name:THEODORE L CONGER D.C., INC
Entity Type:Organization
Organization Name:THEODORE L CONGER D.C., INC
Other - Org Name:CONGER CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CONGER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-530-4802
Mailing Address - Street 1:747 E SOUTH TEMPLE STE 200
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1217
Mailing Address - Country:US
Mailing Address - Phone:801-530-4802
Mailing Address - Fax:801-530-0146
Practice Address - Street 1:747 E SOUTH TEMPLE STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1217
Practice Address - Country:US
Practice Address - Phone:801-530-4802
Practice Address - Fax:801-530-0146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT171096-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4550443OtherAETNA
UT534647011005Medicaid
UT534647011005Medicaid