Provider Demographics
NPI:1770691370
Name:PORTER, KIP C (DC)
Entity type:Individual
Prefix:
First Name:KIP
Middle Name:C
Last Name:PORTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-2743
Mailing Address - Country:US
Mailing Address - Phone:435-833-0977
Mailing Address - Fax:435-833-0978
Practice Address - Street 1:275 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-2743
Practice Address - Country:US
Practice Address - Phone:435-833-0977
Practice Address - Fax:435-833-0978
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3361041202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT639967OtherDMBA
UTQM0000044527OtherALTIUS