Provider Demographics
NPI:1558801258
Name:PHELPS, TERRILL LANE JR (DC, ND)
Entity Type:Individual
Prefix:DR
First Name:TERRILL
Middle Name:LANE
Last Name:PHELPS
Suffix:JR
Gender:M
Credentials:DC, ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 N STATE ROAD 198
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-5668
Mailing Address - Country:US
Mailing Address - Phone:385-200-2047
Mailing Address - Fax:
Practice Address - Street 1:591 N STATE ROAD 198
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-5668
Practice Address - Country:US
Practice Address - Phone:385-200-2047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10250498-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor