Provider Demographics
NPI:1699079723
Name:THE CHIROPRACTIC AVENUE
Entity type:Organization
Organization Name:THE CHIROPRACTIC AVENUE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:NOORDA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-688-2292
Mailing Address - Street 1:169 W 2710 SOUTH CIR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7201
Mailing Address - Country:US
Mailing Address - Phone:435-688-2292
Mailing Address - Fax:
Practice Address - Street 1:169 W 2710 SOUTH CIR
Practice Address - Street 2:SUITE 204
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7201
Practice Address - Country:US
Practice Address - Phone:435-688-2292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7443716-1202111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty