Healthcare Provider Details

I. General information

NPI: 1003088402
Provider Name (Legal Business Name): PROVO SPORTS AND FAMILY CHIROPRACTIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N 500 W STE 205
PROVO UT
84601-1596
US

IV. Provider business mailing address

777 N 500 W STE 205
PROVO UT
84601-1596
US

V. Phone/Fax

Practice location:
  • Phone: 801-375-2420
  • Fax: 801-374-8588
Mailing address:
  • Phone: 801-375-2420
  • Fax: 801-374-8588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number355063-1202
License Number StateUT

VIII. Authorized Official

Name: DR. ERIC J BRADY
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 801-375-2420