Provider Demographics
NPI:1619358488
Name:LUNDELL CHIROPRACTIC
Entity Type:Organization
Organization Name:LUNDELL CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-810-2005
Mailing Address - Street 1:5348 S 1900 W
Mailing Address - Street 2:SUITE #A2
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-3019
Mailing Address - Country:US
Mailing Address - Phone:801-810-2005
Mailing Address - Fax:801-623-6777
Practice Address - Street 1:5348 S 1900 W
Practice Address - Street 2:SUITE #A2
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-3019
Practice Address - Country:US
Practice Address - Phone:801-810-2005
Practice Address - Fax:801-623-6777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7551637-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000069097OtherMEDICARE PTAN