Healthcare Provider Details

I. General information

NPI: 1861574410
Provider Name (Legal Business Name): EAGLE SPORT & FAMILY CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 S FITNESS PL SUITE 110
EAGLE ID
83616-6552
US

IV. Provider business mailing address

547 S FITNESS PL SUITE 110
EAGLE ID
83616-6552
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-3986
  • Fax: 208-319-2700
Mailing address:
  • Phone: 208-939-3986
  • Fax: 208-319-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIA-1073
License Number StateID

VIII. Authorized Official

Name: MR. KRAIG K KNOTTS
Title or Position: OWNER
Credential: D. C.
Phone: 208-939-3986