Provider Demographics
NPI:1528631819
Name:RENEGADE CHIROPRACTIC
Entity type:Organization
Organization Name:RENEGADE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-769-6570
Mailing Address - Street 1:1028 WEST 950 N
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:85047
Mailing Address - Country:US
Mailing Address - Phone:801-769-6570
Mailing Address - Fax:
Practice Address - Street 1:1028 WEST 950 N
Practice Address - Street 2:SUITE 103
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:85047
Practice Address - Country:US
Practice Address - Phone:801-769-6570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-23
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty