Provider Demographics
NPI:1699773671
Name:OPTIMAL HEALTH DYNAMICS PC
Entity type:Organization
Organization Name:OPTIMAL HEALTH DYNAMICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SONDRUP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-476-1752
Mailing Address - Street 1:1117 COUNTRY HILLS DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2559
Mailing Address - Country:US
Mailing Address - Phone:801-476-1752
Mailing Address - Fax:801-476-3075
Practice Address - Street 1:1117 COUNTRY HILLS DR
Practice Address - Street 2:SUITE 2
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2559
Practice Address - Country:US
Practice Address - Phone:801-476-1752
Practice Address - Fax:801-476-3075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT96317081-1202111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
005715101Medicare ID - Type Unspecified
U62190Medicare UPIN