Provider Demographics
NPI:1265581706
Name:FAMILY FOUNDATION CHIROPRACTIC PC
Entity type:Organization
Organization Name:FAMILY FOUNDATION CHIROPRACTIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-842-6382
Mailing Address - Street 1:1121 E 3900 S
Mailing Address - Street 2:STE. 222
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-747-0770
Mailing Address - Fax:801-747-0771
Practice Address - Street 1:1121 E 3900 S
Practice Address - Street 2:STE. 222
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1214
Practice Address - Country:US
Practice Address - Phone:801-747-0770
Practice Address - Fax:801-747-0771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT62621261202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty