MEDICARE: UTAH CHIRO SPORT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NR0400X	Rehabilitation Chiropractor	8490425-1202	UT

General Provider Information

NPI Number	:	1134550650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UTAH CHIRO SPORT

Provider Business Mailing Address
First Line	:	1274 NORTH 25 EAST
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041
Country	:	US
Telephone Number	:	214-960-0718
Fax Number	:

Provider Business Practice Location Address
First Line	:	1274 NORTH 25 EAST
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041
Country	:	US
Telephone Number	:	214-960-0718
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TYLER SEANOA TAUMOLI
Credential	:	D.C.
Telephone Number	:	214-960-0718

Provider Enumeration Date	:	12/09/2013
Last Update Date	:	12/09/2013

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Directions to “UTAH CHIRO SPORT ” Practice Location

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