Provider Demographics
NPI:1508103193
Name:SALT LAKE SPORTS CHIROPRACTIC
Entity Type:Organization
Organization Name:SALT LAKE SPORTS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-402-4840
Mailing Address - Street 1:3980 S 700 E STE 23
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2530
Mailing Address - Country:US
Mailing Address - Phone:801-456-0350
Mailing Address - Fax:801-456-0351
Practice Address - Street 1:3980 S 700 E STE 23
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2530
Practice Address - Country:US
Practice Address - Phone:801-456-0350
Practice Address - Fax:801-456-0351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-15
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8536046-1202261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center