Provider Demographics
NPI:1639350341
Name:COLARUSSO FAMILY CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:COLARUSSO FAMILY CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:COLARUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-878-3645
Mailing Address - Street 1:12571 S. PASTURE ROAD
Mailing Address - Street 2:SUITE E
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7037
Mailing Address - Country:US
Mailing Address - Phone:801-878-3645
Mailing Address - Fax:801-878-3647
Practice Address - Street 1:12571 S. PASTURE ROAD
Practice Address - Street 2:SUITE E
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-7037
Practice Address - Country:US
Practice Address - Phone:801-878-3645
Practice Address - Fax:801-878-3647
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLARUSSO FAMILY CHIROPRACTIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-21
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5072634-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5072634-1202OtherUTAH LICENSE
UT5072634-1202OtherUTAH LICENSE