Basic Information
| Provider Information | |||||||||
| NPI: | 1912984725 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODEN | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | VAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5974 FASHION POINT DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SOUTH OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016211667 | ||||||||
| FaxNumber: | 8014756802 | ||||||||
| Practice Location | |||||||||
| Address1: | 5974 FASHION POINT DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SOUTH OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016211667 | ||||||||
| FaxNumber: | 8014756802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 03/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 3650251202 | UT | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 204574521 | 01 | UT | TAX IDENTIFICATION NUMBER | OTHER |