Provider Demographics
NPI:1487928222
Name:P I C INCORPORATED
Entity type:Organization
Organization Name:P I C INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:GUNDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, FACO
Authorized Official - Phone:801-272-8471
Mailing Address - Street 1:4211 HOLLADAY BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2607
Mailing Address - Country:US
Mailing Address - Phone:801-272-8471
Mailing Address - Fax:
Practice Address - Street 1:4211 HOLLADAY BLVD
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84124-2607
Practice Address - Country:US
Practice Address - Phone:801-272-8471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT161820-1202111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000005652Medicare UPIN