Provider Demographics
NPI:1437301660
Name:GREAT BASIN CHIROPRACTIC P.C.
Entity Type:Organization
Organization Name:GREAT BASIN CHIROPRACTIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:RESETARITS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-363-8899
Mailing Address - Street 1:223 S 700 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2171
Mailing Address - Country:US
Mailing Address - Phone:801-363-8899
Mailing Address - Fax:801-363-1221
Practice Address - Street 1:223 S 700 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2171
Practice Address - Country:US
Practice Address - Phone:801-363-8899
Practice Address - Fax:801-363-1221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT176312-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty