Provider Demographics
NPI:1699811216
Name:GREAT WESTERN CHIROPRACTIC MANAGEMENT
Entity Type:Organization
Organization Name:GREAT WESTERN CHIROPRACTIC MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTOINE
Authorized Official - Middle Name:H
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-224-3661
Mailing Address - Street 1:PO BOX 1232
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-1232
Mailing Address - Country:US
Mailing Address - Phone:801-224-3661
Mailing Address - Fax:801-226-3287
Practice Address - Street 1:382 E 720 S
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-6342
Practice Address - Country:US
Practice Address - Phone:801-224-3661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1508171202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000005617Medicare ID - Type Unspecified