Provider Demographics
NPI:1124100219
Name:FUTRELL, GREGORY DEFOREST (DC)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:DEFOREST
Last Name:FUTRELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7050 HIGHLAND DR STE 140
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CTY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3763
Mailing Address - Country:US
Mailing Address - Phone:801-944-8700
Mailing Address - Fax:801-944-0688
Practice Address - Street 1:7050 HIGHLAND DR STE 140
Practice Address - Street 2:
Practice Address - City:SALT LAKE CTY
Practice Address - State:UT
Practice Address - Zip Code:84121-3763
Practice Address - Country:US
Practice Address - Phone:801-944-8700
Practice Address - Fax:801-944-0688
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2897831202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU90427Medicare UPIN