Provider Demographics
NPI:1972804755
Name:CHIROPRACTIC AVENUE LLC
Entity type:Organization
Organization Name:CHIROPRACTIC AVENUE LLC
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 1:3155 S HIDDEN VALLEY DR
Mailing Address - Street 2:UNIT 175
Mailing Address - City:ST. GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790
Mailing Address - Country:UM
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:2010-11-09
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7443716-1202302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization