Provider Demographics
NPI:1801888730
Name:WHITTAKER, BRET (DC,DABCO)
Entity type:Individual
Prefix:
First Name:BRET
Middle Name:
Last Name:WHITTAKER
Suffix:
Gender:M
Credentials:DC,DABCO
Other - Prefix:
Other - First Name:CARLYLE
Other - Middle Name:BRET
Other - Last Name:WHITTAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC,DABCO
Mailing Address - Street 1:458 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-2846
Mailing Address - Country:US
Mailing Address - Phone:435-896-5656
Mailing Address - Fax:435-896-2842
Practice Address - Street 1:458 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-2846
Practice Address - Country:US
Practice Address - Phone:435-896-5656
Practice Address - Fax:435-896-2842
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT172697-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000069844OtherMEDICARE PTAN
UT190502300OtherFECA-OWCP
UT190502300OtherFECA-OWCP
UT000056035Medicare ID - Type Unspecified