Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 10943391-1202 | UT |
NPI | 1053902106 |
---|---|
Provider Name | Dr. Jedidiah Richard Farley |
First Address | Holladay, UT 84124 |
Second Address | Holladay, UT 84117 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2021 |
Last Update Date | 13/08/2021 |