Provider Demographics
NPI:1750580395
Name:SOUTHEAST CHIROPRACTIC INCORPORATED
Entity type:Organization
Organization Name:SOUTHEAST CHIROPRACTIC INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-637-4621
Mailing Address - Street 1:55 N 600 E
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-2624
Mailing Address - Country:US
Mailing Address - Phone:435-637-4621
Mailing Address - Fax:
Practice Address - Street 1:55 N 600 E
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-2624
Practice Address - Country:US
Practice Address - Phone:435-637-4621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT359704-1202261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
870395551TE5OtherEDUCATORS
50915OtherPEHP
UT530545403012Medicaid
UT46643OtherALTIUS HEALTH PLANS
53054540377001OtherBLUE CROSS BLUE SHIELD/CH