Provider Demographics
NPI:1760669998
Name:DUDLEY CHIROPRACTIC & WELLNESS CENTER LC
Entity Type:Organization
Organization Name:DUDLEY CHIROPRACTIC & WELLNESS CENTER LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-359-3995
Mailing Address - Street 1:1053 E 2100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2349
Mailing Address - Country:US
Mailing Address - Phone:801-359-3995
Mailing Address - Fax:801-359-8489
Practice Address - Street 1:1053 E 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106
Practice Address - Country:US
Practice Address - Phone:801-359-3995
Practice Address - Fax:801-359-8489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057522Medicare PIN