Provider Demographics
NPI:1619131042
Name:WILLOW BEND CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:WILLOW BEND CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:T
Authorized Official - Last Name:HAFEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-673-0900
Mailing Address - Street 1:1054 E RIVERSIDE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4829
Mailing Address - Country:US
Mailing Address - Phone:435-673-0900
Mailing Address - Fax:435-359-5102
Practice Address - Street 1:1054 E RIVERSIDE DR STE 202
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4829
Practice Address - Country:US
Practice Address - Phone:435-673-0900
Practice Address - Fax:435-359-5102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT59761461202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTV08437Medicare UPIN
UT005817201Medicare PIN