Provider Demographics
NPI:1811347008
Name:40TH STREET CHIROPRACTIC AND REHABILITATION, INC
Entity type:Organization
Organization Name:40TH STREET CHIROPRACTIC AND REHABILITATION, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:CAMPBELL
Authorized Official - Last Name:CONLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-682-2765
Mailing Address - Street 1:725 40TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2235
Mailing Address - Country:US
Mailing Address - Phone:801-627-0880
Mailing Address - Fax:801-334-9332
Practice Address - Street 1:725 40TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2235
Practice Address - Country:US
Practice Address - Phone:801-627-0880
Practice Address - Fax:801-334-9332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT361820-1202111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty