Provider Demographics
NPI:1386780906
Name:ALDRIDGE, MARK SWAIN (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:SWAIN
Last Name:ALDRIDGE
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 1:3300 RUNNING CREEK WAY
Mailing Address - Street 2:BLD E STE 200
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5563
Mailing Address - Country:US
Mailing Address - Phone:801-766-2080
Mailing Address - Fax:801-766-4776
Practice Address - Street 1:3300 RUNNING CREEK WAY
Practice Address - Street 2:BLD E STE 200
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-5563
Practice Address - Country:US
Practice Address - Phone:801-766-2080
Practice Address - Fax:801-766-4776
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555765111N00000X
UT328280-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA453363OtherANTHEM PROVIDER NUMBER
VA32-0003223OtherEMPLOYER IDENTIFICATION
350001234Medicare PIN
VA32-0003223OtherEMPLOYER IDENTIFICATION