Healthcare Provider Details

I. General information

NPI: 1134461692
Provider Name (Legal Business Name): ACTIVE ADVANTAGE CHIROPRACTIC AND SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E 770 N
OREM UT
84097-4101
US

IV. Provider business mailing address

616 N 940 W
OREM UT
84057-3652
US

V. Phone/Fax

Practice location:
  • Phone: 801-607-1636
  • Fax:
Mailing address:
  • Phone: 801-874-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number2012-27753
License Number StateUT

VIII. Authorized Official

Name: DR. JAMES GARRETT EAGAR
Title or Position: OWNER
Credential: D.C., ATC
Phone: 801-874-5437