Provider Demographics
NPI:1447607122
Name:BROOKSTAR KNEE CLINIC II
Entity Type:Organization
Organization Name:BROOKSTAR KNEE CLINIC II
Other - Org Name:BROOKSTAR KNEE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEW
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHEELWRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-627-2225
Mailing Address - Street 1:3500 HARRISON BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2038
Mailing Address - Country:US
Mailing Address - Phone:801-627-2225
Mailing Address - Fax:801-627-2228
Practice Address - Street 1:3500 HARRISON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2038
Practice Address - Country:US
Practice Address - Phone:801-627-2225
Practice Address - Fax:801-627-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-23
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty