Provider Demographics
NPI:1447443973
Name:MILLCREEK CHIROPRACTIC LLC
Entity type:Organization
Organization Name:MILLCREEK CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:801-474-2447
Mailing Address - Street 1:4700 S 900 E STE 41G
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4938
Mailing Address - Country:US
Mailing Address - Phone:801-747-2447
Mailing Address - Fax:801-716-3532
Practice Address - Street 1:4700 S 900 E STE 41G
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4938
Practice Address - Country:US
Practice Address - Phone:801-747-2886
Practice Address - Fax:801-716-3532
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST MILLCREEK CHIROPRACTIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-17
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6715760-1202111N00000X, 111NN1001X, 111NR0400X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000062585Medicare UPIN