1689741084 NPI number — SOUTH OGDEN CHIROPRACTIC HEALTH

Table of content: (NPI 1689741084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689741084 NPI number — SOUTH OGDEN CHIROPRACTIC HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH OGDEN CHIROPRACTIC HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689741084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2454 MONROE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OGDEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84401-2506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-675-5600
Provider Business Mailing Address Fax Number:
801-605-3715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2454 MONROE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84401-2506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-675-5600
Provider Business Practice Location Address Fax Number:
801-605-3715
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUNN
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRATARY
Authorized Official Telephone Number:
801-675-5600

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  287585-1202 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 107012083102 . This is a "SELECT HEALTH IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 2238351 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 28758512077001 . This is a "NONTRAD BCBS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 28758512000001 . This is a "TADITIONAL BCBS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 505063944001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 197164 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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