Provider Demographics
NPI:1801133798
Name:LONE PEAK CHIROPRACTIC
Entity type:Organization
Organization Name:LONE PEAK CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALBOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-492-6777
Mailing Address - Street 1:10941 N ALPINE HWY
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-8880
Mailing Address - Country:US
Mailing Address - Phone:801-492-6777
Mailing Address - Fax:801-770-2034
Practice Address - Street 1:10941 N ALPINE HWY
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-8880
Practice Address - Country:US
Practice Address - Phone:801-492-6777
Practice Address - Fax:801-770-2034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6110731-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty