MEDICARE: P I C INCORPORATED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NX0800X	Orthopedic Chiropractor	161820-1202	UT

General Provider Information

NPI Number	:	1487928222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P I C INCORPORATED

Provider Business Mailing Address
First Line	:	4211 HOLLADAY BLVD
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84124-2607
Country	:	US
Telephone Number	:	801-272-8471
Fax Number	:

Provider Business Practice Location Address
First Line	:	4211 HOLLADAY BLVD
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84124-2607
Country	:	US
Telephone Number	:	801-272-8471
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BRUCE VAN GUNDERSEN
Credential	:	DC, FACO
Telephone Number	:	801-272-8471

Provider Enumeration Date	:	02/24/2012
Last Update Date	:	02/24/2012

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Directions to “P I C INCORPORATED ” Practice Location

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