Healthcare Provider Details

I. General information

NPI: 1033507751
Provider Name (Legal Business Name): CAMRON DAVID KOWALLIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 E MAIN ST UNIT F
TREMONTON UT
84337-6733
US

IV. Provider business mailing address

806 E MAIN ST UNIT F
TREMONTON UT
84337-6733
US

V. Phone/Fax

Practice location:
  • Phone: 801-472-3907
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number9182915-1202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: