Provider Demographics
NPI:1093025330
Name:LONGEVITY CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:LONGEVITY CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-777-7701
Mailing Address - Street 1:761 N THORNTON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6105
Mailing Address - Country:US
Mailing Address - Phone:208-777-7701
Mailing Address - Fax:
Practice Address - Street 1:761 N THORNTON ST
Practice Address - Street 2:SUITE A
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6105
Practice Address - Country:US
Practice Address - Phone:208-777-7701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1414111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty