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
StateLicense IDTaxonomies
UT7617785-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty