Healthcare Provider Details

I. General information

NPI: 1669810867
Provider Name (Legal Business Name): SOLOMON GUSTAFSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 W 5300 S
MURRAY UT
84123-5671
US

IV. Provider business mailing address

677 W 5300 S
MURRAY UT
84123-5671
US

V. Phone/Fax

Practice location:
  • Phone: 801-327-8700
  • Fax:
Mailing address:
  • Phone: 801-327-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7996391-1202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: