1316415623 NPI number — ACTIVE LIVING CHIROPRACTIC & WELLNESS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316415623 NPI number — ACTIVE LIVING CHIROPRACTIC & WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE LIVING CHIROPRACTIC & WELLNESS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316415623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13999 W WAINWRIGHT DR STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83713-1969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-939-0775
Provider Business Mailing Address Fax Number:
208-575-6114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13999 W WAINWRIGHT DR STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83713-1969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-939-0775
Provider Business Practice Location Address Fax Number:
208-575-6114
Provider Enumeration Date:
11/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
KRYSTA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING SPECIALIST
Authorized Official Telephone Number:
208-939-0775

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: IDTPID012211 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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