Healthcare Provider Details

I. General information

NPI: 1871549527
Provider Name (Legal Business Name): PATRICK K. MICKELSEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 N HWY 89 STE D
HARRISVILLE UT
84404-2824
US

IV. Provider business mailing address

2240 N HWY 89 STE D
HARRISVILLE UT
84404-2824
US

V. Phone/Fax

Practice location:
  • Phone: 801-782-2947
  • Fax: 801-782-2948
Mailing address:
  • Phone: 801-782-2947
  • Fax: 801-782-2948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6099655-1202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: