Provider Demographics
NPI:1386914737
Name:CHIROPRACTIC SUPPLY NETWORK
Entity type:Organization
Organization Name:CHIROPRACTIC SUPPLY NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAINE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-867-8986
Mailing Address - Street 1:96 N MAIN ST
Mailing Address - Street 2:STE103
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-3055
Mailing Address - Country:US
Mailing Address - Phone:435-867-8986
Mailing Address - Fax:435-867-6233
Practice Address - Street 1:96 N MAIN ST
Practice Address - Street 2:STE 103
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-3055
Practice Address - Country:US
Practice Address - Phone:435-867-8986
Practice Address - Fax:435-867-6233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3346421202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty