Provider Demographics
NPI:1699953752
Name:TOOELE FAMILY CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:TOOELE FAMILY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-882-1621
Mailing Address - Street 1:134 W 1180 N
Mailing Address - Street 2:SUITE #5
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-1483
Mailing Address - Country:US
Mailing Address - Phone:435-882-1621
Mailing Address - Fax:
Practice Address - Street 1:134 W 1180 N
Practice Address - Street 2:SUITE #5
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1483
Practice Address - Country:US
Practice Address - Phone:435-882-1621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT370378-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87039551Medicaid
UT000056279Medicare PIN
UTU82234Medicare UPIN