Provider Demographics
NPI:1124480280
Name:BODY CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:BODY CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:HERRERA
Authorized Official - Last Name:PORTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-871-5652
Mailing Address - Street 1:PO BOX 95307
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0307
Mailing Address - Country:US
Mailing Address - Phone:559-393-4225
Mailing Address - Fax:
Practice Address - Street 1:11075 S STATE ST STE 11B
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-5190
Practice Address - Country:US
Practice Address - Phone:801-871-5652
Practice Address - Fax:888-505-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-27
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9537864-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty