Provider Demographics
NPI:1093975302
Name:SIRUCEK CHIROPRACTIC NEUROLOGY CLINIC, INC.
Entity Type:Organization
Organization Name:SIRUCEK CHIROPRACTIC NEUROLOGY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAX
Authorized Official - Middle Name:KENDRICK
Authorized Official - Last Name:SIRUCEK
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DACNB
Authorized Official - Phone:208-345-7262
Mailing Address - Street 1:3080 E GENTRY WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3544
Mailing Address - Country:US
Mailing Address - Phone:208-345-7262
Mailing Address - Fax:208-343-1953
Practice Address - Street 1:3080 E GENTRY WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3544
Practice Address - Country:US
Practice Address - Phone:208-345-7262
Practice Address - Fax:208-343-1953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1276111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty