Provider Demographics
NPI:1427262195
Name:CANYON RIDGE CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:CANYON RIDGE CHIROPRACTIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS, DACNB
Authorized Official - Phone:801-292-4400
Mailing Address - Street 1:520 MEDICAL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8928
Mailing Address - Country:US
Mailing Address - Phone:801-292-4400
Mailing Address - Fax:844-308-6615
Practice Address - Street 1:520 MEDICAL DR STE 200
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8928
Practice Address - Country:US
Practice Address - Phone:801-292-4400
Practice Address - Fax:844-308-6615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT369867-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT52908255401001OtherBLUE CROSS BLUE SHIELD
UT1427262195OtherNPI GROUP
UT1558391169OtherINDIVIDUAL NPI
UT52908255401001OtherBLUE CROSS BLUE SHIELD
UT350055669Medicare ID - Type UnspecifiedMEDICARE RAILRODA
UT107002314104OtherSELECTHEALTH
UT000056239Medicare PIN
UT1558391169OtherINDIVIDUAL NPI