Provider Demographics
NPI:1861534356
Name:TOOELE VALLEY SPINE CENTER
Entity type:Organization
Organization Name:TOOELE VALLEY SPINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:H
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-883-9200
Mailing Address - Street 1:1244 N MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9839
Mailing Address - Country:US
Mailing Address - Phone:435-833-9200
Mailing Address - Fax:435-833-9223
Practice Address - Street 1:1244 N MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9839
Practice Address - Country:US
Practice Address - Phone:435-833-9200
Practice Address - Fax:435-833-9223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17-6239-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870395551005Medicaid
UT870395551005Medicaid