Provider Demographics
NPI:1679775563
Name:HADDOCK, GREGORY LEWIS (DC)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LEWIS
Last Name:HADDOCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 E 3900 S
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2182
Mailing Address - Country:US
Mailing Address - Phone:801-268-4993
Mailing Address - Fax:
Practice Address - Street 1:715 E 3900 S
Practice Address - Street 2:SUITE 109
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2182
Practice Address - Country:US
Practice Address - Phone:801-268-4993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5770376-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU98502Medicare UPIN