Provider Demographics
NPI:1639785173
Name:SMALLWOOD, KEAGAN TICE (DC)
Entity Type:Individual
Prefix:DR
First Name:KEAGAN
Middle Name:TICE
Last Name:SMALLWOOD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 W BAXTER DR STE 130
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5876
Mailing Address - Country:US
Mailing Address - Phone:853-084-3553
Mailing Address - Fax:
Practice Address - Street 1:912 W BAXTER DR STE 130
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5876
Practice Address - Country:US
Practice Address - Phone:385-308-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14500111N00000X
UT123902991202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor