MEDICARE: FORD FAMILY CHIROPRACTIC AND REJUVENATION CENTER

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	111N00000X	Chiropractor	8062892-1202	UT

General Provider Information

NPI Number	:	1679985576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORD FAMILY CHIROPRACTIC AND REJUVENATION CENTER

Provider Business Mailing Address
First Line	:	101 N FORT LN
Second Line	:	STE.101
City	:	LAYTON
State	:	UT
Zip	:	84041-5682
Country	:	US
Telephone Number	:	801-546-0114
Fax Number	:	801-546-6915

Provider Business Practice Location Address
First Line	:	101 N FORT LN
Second Line	:	STE.101
City	:	LAYTON
State	:	UT
Zip	:	84041-5682
Country	:	US
Telephone Number	:	801-546-0114
Fax Number	:	801-546-6915

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. BRAD LAMAR MILLER
Credential	:	D.C.
Telephone Number	:	801-546-0114

Provider Enumeration Date	:	05/27/2014
Last Update Date	:	05/27/2014

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