Healthcare Provider Details

I. General information

NPI: 1730192600
Provider Name (Legal Business Name): ALTA VISTA CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1781 W 9000 S
WEST JORDAN UT
84088-6502
US

IV. Provider business mailing address

1781 W 9000 S
WEST JORDAN UT
84088-6502
US

V. Phone/Fax

Practice location:
  • Phone: 801-562-5600
  • Fax: 801-255-7104
Mailing address:
  • Phone: 801-562-5600
  • Fax: 801-255-7104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number357290-1202
License Number StateUT

VIII. Authorized Official

Name: DR. STEPHANIE JEAN ALLEN
Title or Position: OWNER
Credential: DC
Phone: 801-562-5600