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General NPI Number Information
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NPI Number | 1174336531
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Entity Type | Organization
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Legal Business Name | TRIPLE CCCA
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Dates
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Enumeration Date | 01/29/2025
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Last Update Date | 01/29/2025
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Provider Practice Location Address
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Address Line | 45 W MAIN STREET CT STE 100
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City | ALPINE
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State | UT
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Zip | 84004-5701
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Country | US
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Telephone | 801-492-0206
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Fax | 801-492-0037
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Provider Business Mailing Address
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Address Line | 45 W MAIN STREET CT STE 100
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City | ALPINE
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State | UT
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Zip | 84004-5701
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Country | US
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Telephone | 801-492-0206
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Fax | 801-492-0037
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Authorized Official
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Title or Position | DOCTOR, CEO
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Name | JOSHUA CLARK
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Credential | DC
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Telephone | 801-492-0206
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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