Provider Demographics
NPI:1942407333
Name:CELEBRATE LIFE WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:CELEBRATE LIFE WELLNESS CENTER, LLC
Other - Org Name:BRESHEARS CHIROPRACTIC LIFE CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRESHEARS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-866-1490
Mailing Address - Street 1:7750 W CRESTWOOD DRIVE #1
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-376-5433
Mailing Address - Fax:208-376-5636
Practice Address - Street 1:7750 W CRESTWOOD DRIVE #1
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-376-5433
Practice Address - Fax:208-376-5636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA428111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT44468Medicare UPIN