Provider Demographics
NPI:1851706329
Name:ALPINE SPINAL HEALTH
Entity Type:Organization
Organization Name:ALPINE SPINAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-374-2774
Mailing Address - Street 1:3325 N UNIVERSITY AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6615
Mailing Address - Country:US
Mailing Address - Phone:801-374-2774
Mailing Address - Fax:801-292-7188
Practice Address - Street 1:3325 N UNIVERSITY AVE STE 125
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6615
Practice Address - Country:US
Practice Address - Phone:801-374-2774
Practice Address - Fax:801-292-7188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1668441202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty