Provider Demographics
NPI:1700135233
Name:SOUTH JORDAN HEALTH AND WELLNESS
Entity type:Organization
Organization Name:SOUTH JORDAN HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-882-1621
Mailing Address - Street 1:272 N BROADWAY ST
Mailing Address - Street 2:#11
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-2244
Mailing Address - Country:US
Mailing Address - Phone:435-882-1621
Mailing Address - Fax:435-882-8267
Practice Address - Street 1:272 N BROADWAY ST
Practice Address - Street 2:#11
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-2244
Practice Address - Country:US
Practice Address - Phone:435-882-1621
Practice Address - Fax:435-882-8267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT370378-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT3703781202OtherSTATE LICENSE