Provider Demographics
NPI:1215242094
Name:SKYLINE CHIROPRACTIC
Entity type:Organization
Organization Name:SKYLINE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-675-5600
Mailing Address - Street 1:1893 SKYLINE DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5218
Mailing Address - Country:US
Mailing Address - Phone:801-675-5600
Mailing Address - Fax:801-393-4589
Practice Address - Street 1:1893 SKYLINE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5218
Practice Address - Country:US
Practice Address - Phone:801-675-5600
Practice Address - Fax:801-393-4589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2875851202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057113Medicare PIN
UTU92794Medicare UPIN