Provider Demographics
NPI:1184118028
Name:BEN LOMOND CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:BEN LOMOND CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-782-0987
Mailing Address - Street 1:428 E 2600 N
Mailing Address - Street 2:STE #5
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414
Mailing Address - Country:US
Mailing Address - Phone:801-782-0987
Mailing Address - Fax:801-782-7518
Practice Address - Street 1:428 E 2600 N
Practice Address - Street 2:STE #5
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414
Practice Address - Country:US
Practice Address - Phone:801-782-0987
Practice Address - Fax:801-782-7518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6929478-1202111N00000X
UT5960456-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528651166001Medicaid
UT59604561200001OtherBLUE CROSS