=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790259828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UTAH CHIROPRACTIC AND REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2019
-----------------------------------------------------
Last Update Date | 01/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 321 E 300 N STE B
-----------------------------------------------------
City | AMERICAN FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84003-1790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-692-3231
-----------------------------------------------------
Fax | 801-820-2860
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 321 E 300 N STE B
-----------------------------------------------------
City | AMERICAN FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84003-1790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-692-3231
-----------------------------------------------------
Fax | 801-820-2860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | BRUCE MACDONALD
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 801-762-7009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------