Basic Information
| Provider Information | |||||||||
| NPI: | 1104891084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 218 E 800 S | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840585008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012252457 | ||||||||
| FaxNumber: | 8012252537 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 E 800 S | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012252457 | ||||||||
| FaxNumber: | 8012252537 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 05/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 1640901202 | UT | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 350002765 | 01 | RAILROAD MEDICARE | OTHER |