Provider Demographics
NPI:1801832241
Name:ERICKSON, NEIL LOUIS (DC DABCO CCSP)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:LOUIS
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:DC DABCO CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 N GATEWAY DR STE 223
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9856
Mailing Address - Country:US
Mailing Address - Phone:435-752-2772
Mailing Address - Fax:435-752-2878
Practice Address - Street 1:169 N GATEWAY DR STE 223
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9856
Practice Address - Country:US
Practice Address - Phone:435-752-2772
Practice Address - Fax:435-752-2878
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT83-169476-1202111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT78064Medicare UPIN
UT005732101Medicare ID - Type Unspecified