Provider Demographics
NPI:1851496467
Name:PRIDEAUX, DANIEL R (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:PRIDEAUX
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SW HIGGINS AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1341
Mailing Address - Country:US
Mailing Address - Phone:406-721-4425
Mailing Address - Fax:406-721-4426
Practice Address - Street 1:1001 SW HIGGINS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1341
Practice Address - Country:US
Practice Address - Phone:406-721-4425
Practice Address - Fax:406-721-4426
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT437111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4142-0OtherBC/BS
MT000004088Medicare ID - Type UnspecifiedMEDICARE