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General NPI Number Information
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NPI Number | 1134461692
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Entity Type | Organization
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Legal Business Name | ACTIVE ADVANTAGE CHIROPRACTIC AND SPORTS MEDICINE
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Dates
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Enumeration Date | 03/22/2013
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Last Update Date | 03/22/2013
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Provider Practice Location Address
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Address Line | 510 E 770 N
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City | OREM
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State | UT
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Zip | 84097-4101
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Country | US
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Telephone | 801-607-1636
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Fax |
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Provider Business Mailing Address
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Address Line | 616 N 940 W
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City | OREM
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State | UT
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Zip | 84057-3652
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Country | US
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Telephone | 801-874-5437
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JAMES GARRETT EAGAR
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Credential | D.C., ATC
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Telephone | 801-874-5437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number | 2012-27753
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License Number State | UT
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