Healthcare Provider Details

I. General information

NPI: 1659641827
Provider Name (Legal Business Name): PACK CHIROPRACTIC CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2565 TYLER AVE
OGDEN UT
84401-2818
US

IV. Provider business mailing address

2565 TYLER AVE
OGDEN UT
84401-2818
US

V. Phone/Fax

Practice location:
  • Phone: 801-245-9010
  • Fax:
Mailing address:
  • Phone: 801-245-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1305
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number1305
License Number StateOH

VIII. Authorized Official

Name: DAVID PACK
Title or Position: PRESIDENT
Credential: DC
Phone: 801-245-9010