Healthcare Provider Details

I. General information

NPI: 1043485188
Provider Name (Legal Business Name): MT. OLYMPUS CLINIC OF CHIROPRACTIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E 3900 S SUITE 205-A
SALT LAKE CITY UT
84107-2182
US

IV. Provider business mailing address

715 E 3900 S SUITE 205-A
SALT LAKE CITY UT
84107-2182
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-4993
  • Fax: 801-268-4241
Mailing address:
  • Phone: 801-268-4993
  • Fax: 801-268-4241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number57703761202
License Number StateUT

VIII. Authorized Official

Name: DR. GREGORY LEWIS HADDOCK
Title or Position: OWNER
Credential: D.C.
Phone: 801-268-4993