Provider Demographics
NPI:1588967301
Name:SOUTHWEST CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:SOUTHWEST CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:NIEL
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-254-9400
Mailing Address - Street 1:10358 S 1700 W
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-9339
Mailing Address - Country:US
Mailing Address - Phone:801-254-9400
Mailing Address - Fax:801-254-5739
Practice Address - Street 1:10358 S 1700 W
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-9339
Practice Address - Country:US
Practice Address - Phone:801-254-9400
Practice Address - Fax:801-254-5739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870503754002Medicaid
UT870503754002Medicaid