=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053583880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BABCOCK WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2008
-----------------------------------------------------
Last Update Date | 04/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9265-A S REDWOOD RD
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-565-1411
-----------------------------------------------------
Fax | 801-565-1411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9265-A S REDWOOD RD
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-565-1411
-----------------------------------------------------
Fax | 801-565-1411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRANDON L BABCOCK
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 801-565-1411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 51894851202
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------