Provider Demographics
NPI:1902943863
Name:CACHE VALLEY CHIROPRACTIC CLINIC LLC
Entity type:Organization
Organization Name:CACHE VALLEY CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-752-2772
Mailing Address - Street 1:169 N GATEWAY DR STE 223
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9856
Mailing Address - Country:US
Mailing Address - Phone:435-752-7722
Mailing Address - Fax:435-752-2878
Practice Address - Street 1:169 N GATEWAY DR STE 223
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9856
Practice Address - Country:US
Practice Address - Phone:435-752-2772
Practice Address - Fax:435-752-2878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT169476-1202111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT22321OtherPEHP
UT10294OtherALTIUS
UT519720002009Medicaid
UT94287113577001OtherBLUE CROSS BLUE SHIELD
UT870395551ER1OtherEMIA
UT94287113577001OtherBLUE CROSS BLUE SHIELD