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General NPI Number Information
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NPI Number | 1881711349
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Entity Type | Organization
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Legal Business Name | MOUNT MAHOGANY PC
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Dates
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Enumeration Date | 03/22/2007
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Last Update Date | 07/18/2014
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Provider Practice Location Address
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Address Line | 66 E STATE RD
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City | PLEASANT GROVE
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State | UT
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Zip | 84062-2637
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Country | US
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Telephone | 801-796-7961
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Fax | 801-796-1104
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Provider Business Mailing Address
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Address Line | 66 E STATE RD
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City | PLEASANT GROVE
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State | UT
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Zip | 84062-2637
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Country | US
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Telephone | 801-796-7961
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Fax | 801-796-1104
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. FAXON D MOULDER
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Credential | D.C.
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Telephone | 801-796-7961
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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 | 2774319-1202
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License Number State | UT
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