Provider Demographics
NPI:1134461692
Name:ACTIVE ADVANTAGE CHIROPRACTIC AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:ACTIVE ADVANTAGE CHIROPRACTIC AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:EAGAR
Authorized Official - Suffix:
Authorized Official - Credentials:DC, ATC
Authorized Official - Phone:801-874-5437
Mailing Address - Street 1:616 N 940 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3652
Mailing Address - Country:US
Mailing Address - Phone:801-874-5437
Mailing Address - Fax:
Practice Address - Street 1:510 E 770 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-4101
Practice Address - Country:US
Practice Address - Phone:801-607-1636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2012-27753261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation