Healthcare Provider Details

I. General information

NPI: 1447443973
Provider Name (Legal Business Name): MILLCREEK CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 S 900 E STE 41G
SALT LAKE CITY UT
84117-4938
US

IV. Provider business mailing address

4700 S 900 E STE 41G
SALT LAKE CITY UT
84117-4938
US

V. Phone/Fax

Practice location:
  • Phone: 801-747-2886
  • Fax: 801-716-3532
Mailing address:
  • Phone: 801-747-2447
  • Fax: 801-716-3532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number6715760-1202
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number6715760-1202
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number6715760-1202
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6715760-1202
License Number StateUT

VIII. Authorized Official

Name: DR. THOMAS E GRANT JR.
Title or Position: OWNER MANAGER
Credential: D.C.
Phone: 801-474-2447