Provider Demographics
NPI:1316415623
Name:ACTIVE LIVING CHIROPRACTIC & WELLNESS LLC
Entity Type:Organization
Organization Name:ACTIVE LIVING CHIROPRACTIC & WELLNESS LLC
Other - Org Name:ACTIVE LIVING CHIROPRACTIC AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRYSTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-939-0775
Mailing Address - Street 1:13999 W WAINWRIGHT DR STE 201
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1969
Mailing Address - Country:US
Mailing Address - Phone:208-939-0775
Mailing Address - Fax:208-575-6114
Practice Address - Street 1:13999 W WAINWRIGHT DR STE 201
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1969
Practice Address - Country:US
Practice Address - Phone:208-939-0775
Practice Address - Fax:208-575-6114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-05
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID012211Medicaid