Healthcare Provider Details

I. General information

NPI: 1699079723
Provider Name (Legal Business Name): THE CHIROPRACTIC AVENUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 W 2710 SOUTH CIR SUITE 204
ST GEORGE UT
84790-7201
US

IV. Provider business mailing address

169 W 2710 SOUTH CIR SUITE 204
ST GEORGE UT
84790-7201
US

V. Phone/Fax

Practice location:
  • Phone: 435-688-2292
  • Fax:
Mailing address:
  • Phone: 435-688-2292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number7443716-1202
License Number StateUT

VIII. Authorized Official

Name: DR. BRENT DAVID NOORDA
Title or Position: MANAGING PARTNER
Credential: D.C.
Phone: 435-688-2292