Provider Demographics
NPI:1295012623
Name:SUMMIT FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:SUMMIT FAMILY CHIROPRACTIC
Other - Org Name:SUMMIT FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-771-4474
Mailing Address - Street 1:2634 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-3750
Mailing Address - Country:US
Mailing Address - Phone:208-771-4474
Mailing Address - Fax:208-664-1001
Practice Address - Street 1:2634 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-3750
Practice Address - Country:US
Practice Address - Phone:208-771-4474
Practice Address - Fax:208-664-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1447111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty