Provider Demographics
NPI:1669654935
Name:SIRUCEK, DAX (DC, DACNB)
Entity Type:Individual
Prefix:DR
First Name:DAX
Middle Name:
Last Name:SIRUCEK
Suffix:
Gender:M
Credentials:DC, DACNB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 E GENTRY WAY
Mailing Address - Street 2:110
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3544
Mailing Address - Country:US
Mailing Address - Phone:208-345-7262
Mailing Address - Fax:208-343-1953
Practice Address - Street 1:3080 E GENTRY WAY
Practice Address - Street 2:110
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3544
Practice Address - Country:US
Practice Address - Phone:208-345-7262
Practice Address - Fax:208-343-1953
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1276111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1682024Medicare UPIN