Provider Demographics
NPI: | 1639485014 |
---|---|
Name: | GREAT BASIN SPINE AND SPORTS |
Entity Type: | Organization |
Organization Name: | GREAT BASIN SPINE AND SPORTS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | SINGLE MEMBER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MICHAEL |
Authorized Official - Middle Name: | GREGORY |
Authorized Official - Last Name: | GRAVES |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 801-627-2023 |
Mailing Address - Street 1: | 134 E 4600 S |
Mailing Address - Street 2: | |
Mailing Address - City: | WASHINGTON TERRACE |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84405-5946 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 801-627-2023 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 134 E 4600 S |
Practice Address - Street 2: | |
Practice Address - City: | WASHINGTON TERRACE |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84405-5946 |
Practice Address - Country: | US |
Practice Address - Phone: | 801-627-2023 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-08-24 |
Last Update Date: | 2010-12-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
UT | 7617785-1202 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Single Specialty |