Provider Demographics
NPI:1659641827
Name:PACK CHIROPRACTIC CLINIC, INC
Entity Type:Organization
Organization Name:PACK CHIROPRACTIC CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-245-9010
Mailing Address - Street 1:2565 TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-2818
Mailing Address - Country:US
Mailing Address - Phone:801-245-9010
Mailing Address - Fax:
Practice Address - Street 1:2565 TYLER AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-2818
Practice Address - Country:US
Practice Address - Phone:801-245-9010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1305111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty