Provider Demographics
NPI:1891044889
Name:STUCKY CHIROPRACTIC PC
Entity type:Organization
Organization Name:STUCKY CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:L
Authorized Official - Last Name:STUCKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-245-3500
Mailing Address - Street 1:130 N 800 E
Mailing Address - Street 2:
Mailing Address - City:HYRUM
Mailing Address - State:UT
Mailing Address - Zip Code:84319-1150
Mailing Address - Country:US
Mailing Address - Phone:435-245-3500
Mailing Address - Fax:435-755-2913
Practice Address - Street 1:130 N 800 E
Practice Address - Street 2:
Practice Address - City:HYRUM
Practice Address - State:UT
Practice Address - Zip Code:84319-1150
Practice Address - Country:US
Practice Address - Phone:435-245-3500
Practice Address - Fax:435-245-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2857381202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U48620Medicare UPIN