Provider Demographics
NPI:1558517771
Name:ASPEN FALLS SPINAL CARE CENTER LLC
Entity Type:Organization
Organization Name:ASPEN FALLS SPINAL CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HEDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-363-0060
Mailing Address - Street 1:505 E 200 S
Mailing Address - Street 2:STE 425
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2022
Mailing Address - Country:US
Mailing Address - Phone:801-363-0060
Mailing Address - Fax:801-363-3926
Practice Address - Street 1:505 E 200 S
Practice Address - Street 2:STE 425
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2022
Practice Address - Country:US
Practice Address - Phone:801-363-0060
Practice Address - Fax:801-363-3926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS67900091202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1831383298OtherINDIVIDUAL NPI NUMBER