MEDICARE: DR. TERRILL LANE PHELPS JR. DC, ND

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	111N00000X	Chiropractor	10250498-1202	ID

General Provider Information

NPI Number	:	1558801258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRILL LANE PHELPS JR. DC, ND

Provider Business Mailing Address
First Line	:	591 N STATE ROAD 198
Second Line	:
City	:	SALEM
State	:	UT
Zip	:	84653-5668
Country	:	US
Telephone Number	:	385-200-2047
Fax Number	:

Provider Business Practice Location Address
First Line	:	591 N STATE ROAD 198
Second Line	:
City	:	SALEM
State	:	UT
Zip	:	84653-5668
Country	:	US
Telephone Number	:	385-200-2047
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2017
Last Update Date	:	02/28/2017

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