Provider Demographics
NPI:1396139432
Name:CANYON CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:CANYON CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-763-8662
Mailing Address - Street 1:5337 W 11000 N
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003
Mailing Address - Country:US
Mailing Address - Phone:801-763-8662
Mailing Address - Fax:801-763-8664
Practice Address - Street 1:5337 W 11000 N
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003
Practice Address - Country:US
Practice Address - Phone:801-763-8662
Practice Address - Fax:801-763-8664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT931759851201111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000056085OtherMEDICARE ID- TYPE UNSPECIFIED
UT000056085OtherMEDICARE ID- TYPE UNSPECIFIED