Provider Demographics
NPI:1578529921
Name:EGBERT, MICHAEL R (DC, FACO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:EGBERT
Suffix:
Gender:M
Credentials:DC, FACO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7669 S 1700 W
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-4007
Mailing Address - Country:US
Mailing Address - Phone:801-566-2449
Mailing Address - Fax:801-566-5435
Practice Address - Street 1:7669 S 1700 W
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-4007
Practice Address - Country:US
Practice Address - Phone:801-566-2449
Practice Address - Fax:801-566-5435
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT160276-1202111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT201332189OtherEIN
UT000005714Medicare ID - Type Unspecified
UT201332189OtherEIN