Provider Demographics
NPI:1598179210
Name:BLAINE UPHAM DC PC
Entity Type:Organization
Organization Name:BLAINE UPHAM DC PC
Other - Org Name:MOUNTAIN VIEW CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:UPHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:907-357-6688
Mailing Address - Street 1:5461 E MAYFLOWER LN
Mailing Address - Street 2:SUITE # 6
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7892
Mailing Address - Country:US
Mailing Address - Phone:907-357-6688
Mailing Address - Fax:907-357-9655
Practice Address - Street 1:5461 E MAYFLOWER LN
Practice Address - Street 2:SUITE # 6
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7892
Practice Address - Country:US
Practice Address - Phone:907-357-6688
Practice Address - Fax:907-357-9655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK584111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty