Provider Demographics
NPI:1194033720
Name:FOOTHILLS CHIROPRACTIC CENTER, PC
Entity Type:Organization
Organization Name:FOOTHILLS CHIROPRACTIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:PRIDEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-721-4425
Mailing Address - Street 1:1001 SW HIGGINS AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1341
Mailing Address - Country:US
Mailing Address - Phone:406-721-4425
Mailing Address - Fax:406-721-4426
Practice Address - Street 1:1001 SW HIGGINS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1341
Practice Address - Country:US
Practice Address - Phone:406-721-4425
Practice Address - Fax:406-721-4426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT437111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty