Provider Demographics
NPI:1881094431
Name:WASATCH SPORTS AND FAMILY CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:WASATCH SPORTS AND FAMILY CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:940-453-7602
Mailing Address - Street 1:5442 W 10030 N
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9170
Mailing Address - Country:US
Mailing Address - Phone:940-453-7602
Mailing Address - Fax:
Practice Address - Street 1:230 N 1200 E
Practice Address - Street 2:102
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-5865
Practice Address - Country:US
Practice Address - Phone:940-453-7602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6374884-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty