Healthcare Provider Details

I. General information

NPI: 1437549706
Provider Name (Legal Business Name): BACK IN ACTION CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 N STATE ST
PRESTON ID
83263-1153
US

IV. Provider business mailing address

645 N STATE ST
PRESTON ID
83263-1153
US

V. Phone/Fax

Practice location:
  • Phone: 208-852-0411
  • Fax: 208-485-8045
Mailing address:
  • Phone: 208-852-0411
  • Fax: 208-485-8045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-1544
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIA-1544
License Number StateID

VIII. Authorized Official

Name: DR. MICHAEL EARLEY
Title or Position: PRESIDENT
Credential: DC
Phone: 435-554-8827