Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 6763842-1202 | UT |
N | 111NX0100X | Occupational Health | 6763842-1202 | UT |
NPI | 1003055534 |
---|---|
Provider Name | Brigham Lundahl |
First Address | St George, UT 84770-3352 |
Second Address | St George, UT 84770-3352 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2009 |
Last Update Date | 06/11/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U000075270 | (02) | UT |