Provider Demographics
NPI:1376107821
Name:ACTIVE FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:ACTIVE FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-968-9688
Mailing Address - Street 1:1002 E LEGACY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1764
Mailing Address - Country:US
Mailing Address - Phone:208-968-9688
Mailing Address - Fax:
Practice Address - Street 1:2973 N EAGLE RD STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6251
Practice Address - Country:US
Practice Address - Phone:208-968-9688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-30
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty