Provider Demographics
NPI:1689741084
Name:SOUTH OGDEN CHIROPRACTIC HEALTH
Entity Type:Organization
Organization Name:SOUTH OGDEN CHIROPRACTIC HEALTH
Other - Org Name:SKYLINE CHIROPRACTIC
Other - Org Type:Other Name
Authorized Official - Title/Position:SECRATARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-675-5600
Mailing Address - Street 1:2454 MONROE BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-2506
Mailing Address - Country:US
Mailing Address - Phone:801-675-5600
Mailing Address - Fax:801-605-3715
Practice Address - Street 1:2454 MONROE BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-2506
Practice Address - Country:US
Practice Address - Phone:801-675-5600
Practice Address - Fax:801-605-3715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT287585-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107012083102OtherSELECT HEALTH IHC
UT2238351OtherUNITED HEALTH CARE
UT28758512077001OtherNONTRAD BCBS
UT28758512000001OtherTADITIONAL BCBS
UT505063944001Medicaid
UT197164OtherALTIUS
UT2238351OtherUNITED HEALTH CARE
UT107012083102OtherSELECT HEALTH IHC