Provider Demographics
NPI:1700060381
Name:BLUE MOUNTAIN CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:BLUE MOUNTAIN CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-587-3255
Mailing Address - Street 1:PO BOX 783
Mailing Address - Street 2:225 SO. MAIN
Mailing Address - City:MONTICELLO
Mailing Address - State:UT
Mailing Address - Zip Code:84535-0783
Mailing Address - Country:US
Mailing Address - Phone:435-587-3255
Mailing Address - Fax:435-587-3442
Practice Address - Street 1:225 SO. MAIN
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535-0783
Practice Address - Country:US
Practice Address - Phone:435-587-3255
Practice Address - Fax:435-587-3442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT176449-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870395551005Medicaid