Provider Demographics
NPI:1851592141
Name:INTERMOUNTAIN CHIROPRACTIC AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:INTERMOUNTAIN CHIROPRACTIC AND SPORTS MEDICINE
Other - Org Name:COOK CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VELOY
Authorized Official - Middle Name:K
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-798-6558
Mailing Address - Street 1:642 E. KIRBY LN.
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-5753
Mailing Address - Country:US
Mailing Address - Phone:801-798-6558
Mailing Address - Fax:801-798-3690
Practice Address - Street 1:642 E. KIRBY LN.
Practice Address - Street 2:SUITE 103
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-5753
Practice Address - Country:US
Practice Address - Phone:801-798-6558
Practice Address - Fax:801-798-3690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5128490-1202111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty