MEDICARE: DR. BRUCE VAN GUNDERSEN DC, FACO

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	111NX0800X	Orthopedic Chiropractor	161820-1202	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	161820-1202	OTHER	UT	STATE LICENSE

General Provider Information

NPI Number	:	1952409476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE VAN GUNDERSEN DC, FACO

Provider Business Mailing Address
First Line	:	4211 HOLLADAY BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2607
Country	:	US
Telephone Number	:	801-272-8471
Fax Number	:	801-424-2219

Provider Business Practice Location Address
First Line	:	4211 HOLLADAY BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2607
Country	:	US
Telephone Number	:	801-272-8471
Fax Number	:	801-424-2219

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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