Provider Demographics
NPI:1588676738
Name:CONGER, THEODORE L (D C)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:L
Last Name:CONGER
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 E SOUTH TEMPLE STE 200
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1217
Mailing Address - Country:US
Mailing Address - Phone:801-530-4802
Mailing Address - Fax:
Practice Address - Street 1:747 E SOUTH TEMPLE STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1217
Practice Address - Country:US
Practice Address - Phone:801-530-4802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT171096-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4550443OtherAETNA
UT350011548OtherRR RETIREMENT
UTTPRA10671OtherMOLINA HEALTHCARE
UT107000433103OtherIHC HEALTH PLANS