Healthcare Provider Details

I. General information

NPI: 1063176170
Provider Name (Legal Business Name): ISA5417, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 E MYRTLE AVE STE 100
MURRAY UT
84107-4850
US

IV. Provider business mailing address

14439 NW MILITARY HWY STE 108-449
SHAVANO PARK TX
78231-1646
US

V. Phone/Fax

Practice location:
  • Phone: 801-210-5050
  • Fax: 801-210-5050
Mailing address:
  • Phone: 210-249-4949
  • Fax: 210-249-4949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: BLANCA YURAIMA CORRIE
Title or Position: MANAGING MEMBER
Credential:
Phone: 210-249-4949