Provider Demographics
NPI:1659091874
Name:PRIMAL PRACTICE
Entity Type:Organization
Organization Name:PRIMAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-549-8969
Mailing Address - Street 1:235 N 1ST ST W STE A
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3661
Mailing Address - Country:US
Mailing Address - Phone:406-549-8969
Mailing Address - Fax:
Practice Address - Street 1:235 N 1ST ST W STE A
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-3661
Practice Address - Country:US
Practice Address - Phone:406-549-8969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-29
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty