Healthcare Provider Details

I. General information

NPI: 1710720636
Provider Name (Legal Business Name): TROY J RAVEN JR. DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 E STATE RD
PLEASANT GROVE UT
84062-3617
US

IV. Provider business mailing address

316 E STATE RD
PLEASANT GROVE UT
84062-3617
US

V. Phone/Fax

Practice location:
  • Phone: 801-400-8732
  • Fax:
Mailing address:
  • Phone: 801-400-8732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number12972586-1202
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number12972586-1202
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number12972586-1202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: