Provider Demographics
NPI:1396135588
Name:MONROE MOUNTAIN CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:MONROE MOUNTAIN CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DASTRUP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-527-0987
Mailing Address - Street 1:57 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:UT
Mailing Address - Zip Code:84754-4578
Mailing Address - Country:US
Mailing Address - Phone:435-527-0987
Mailing Address - Fax:
Practice Address - Street 1:57 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:UT
Practice Address - Zip Code:84754-4578
Practice Address - Country:US
Practice Address - Phone:435-527-0987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9169105-1202261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center