Provider Demographics
NPI:1366713307
Name:GONSTEAD FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:GONSTEAD FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:DARRELL
Authorized Official - Last Name:CHENEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-425-2065
Mailing Address - Street 1:1154 S. 300 W.
Mailing Address - Street 2:SUITE C
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101
Mailing Address - Country:US
Mailing Address - Phone:801-425-2065
Mailing Address - Fax:801-742-8540
Practice Address - Street 1:1154 S. 300 W.
Practice Address - Street 2:SUITE C
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101
Practice Address - Country:US
Practice Address - Phone:801-425-2065
Practice Address - Fax:801-742-8540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5309691-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty