Healthcare Provider Details

I. General information

NPI: 1265714356
Provider Name (Legal Business Name): UPPER CERVICAL CHIROPRACTIC OF UTAH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 W 520 N
OREM UT
84057-4696
US

IV. Provider business mailing address

239 W 520 N
OREM UT
84057-4696
US

V. Phone/Fax

Practice location:
  • Phone: 801-224-1121
  • Fax: 801-224-7151
Mailing address:
  • Phone: 801-224-1121
  • Fax: 801-224-7151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number80411041202
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ASHLEIGH STREET
Title or Position: OWNER
Credential: DC
Phone: 801-224-1121