Provider Demographics
NPI:1386759454
Name:UTAH SPINAL HEALTH AND REHABILITATION PC
Entity type:Organization
Organization Name:UTAH SPINAL HEALTH AND REHABILITATION PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:NEPHI
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-798-2515
Mailing Address - Street 1:205 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1726
Mailing Address - Country:US
Mailing Address - Phone:801-798-2515
Mailing Address - Fax:801-798-2510
Practice Address - Street 1:205 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1726
Practice Address - Country:US
Practice Address - Phone:801-798-2515
Practice Address - Fax:801-798-2510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6089352-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTUT04550Medicare UPIN