Provider Demographics
NPI:1407260318
Name:EAGLE INTEGRATED MEDICINE
Entity Type:Organization
Organization Name:EAGLE INTEGRATED MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:AZELTINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:971-322-9791
Mailing Address - Street 1:PO BOX 2259
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-2259
Mailing Address - Country:US
Mailing Address - Phone:970-328-1200
Mailing Address - Fax:970-328-1600
Practice Address - Street 1:717A SYLVAN LAKE RD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631
Practice Address - Country:US
Practice Address - Phone:970-328-1200
Practice Address - Fax:970-328-1600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6195111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty