Provider Demographics
NPI:1871752642
Name:MARK HENRY RADANDT
Entity type:Organization
Organization Name:MARK HENRY RADANDT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:RADANDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-756-0111
Mailing Address - Street 1:98 W STATE RD
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-1486
Mailing Address - Country:US
Mailing Address - Phone:801-756-0111
Mailing Address - Fax:
Practice Address - Street 1:98 W STATE RD
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-1486
Practice Address - Country:US
Practice Address - Phone:801-756-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT355858-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty