1619358488 NPI number — LUNDELL CHIROPRACTIC

Table of content: (NPI 1619358488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619358488 NPI number — LUNDELL CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUNDELL CHIROPRACTIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619358488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5348 S 1900 W
Provider Second Line Business Mailing Address:
SUITE #A2
Provider Business Mailing Address City Name:
ROY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84067-3019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-810-2005
Provider Business Mailing Address Fax Number:
801-623-6777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5348 S 1900 W
Provider Second Line Business Practice Location Address:
SUITE #A2
Provider Business Practice Location Address City Name:
ROY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84067-3019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-810-2005
Provider Business Practice Location Address Fax Number:
801-623-6777
Provider Enumeration Date:
06/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LUNDELL
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, CHIROPRACTOR
Authorized Official Telephone Number:
801-810-2005

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  7551637-1202 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000069097 . This is a "MEDICARE PTAN" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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