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General NPI Number Information
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NPI Number | 1003088402
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Entity Type | Organization
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Legal Business Name | PROVO SPORTS AND FAMILY CHIROPRACTIC, INC.
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Dates
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Enumeration Date | 03/26/2008
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Last Update Date | 03/28/2008
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Provider Practice Location Address
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Address Line | 777 N 500 W STE 205
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City | PROVO
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State | UT
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Zip | 84601-1596
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Country | US
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Telephone | 801-375-2420
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Fax | 801-374-8588
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Provider Business Mailing Address
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Address Line | 777 N 500 W STE 205
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City | PROVO
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State | UT
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Zip | 84601-1596
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Country | US
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Telephone | 801-375-2420
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Fax | 801-374-8588
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. ERIC J BRADY
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Credential | D.C.
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Telephone | 801-375-2420
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | 355063-1202
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License Number State | UT
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