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General NPI Number Information
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NPI Number | 1295012623
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Entity Type | Organization
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Legal Business Name | SUMMIT FAMILY CHIROPRACTIC
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Dates
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Enumeration Date | 11/14/2011
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Last Update Date | 12/19/2016
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Provider Practice Location Address
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Address Line | 2634 N GOVERNMENT WAY
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City | COEUR D ALENE
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State | ID
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Zip | 83815-3750
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Country | US
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Telephone | 208-771-4474
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Fax | 208-664-1001
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Provider Business Mailing Address
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Address Line | 2634 N GOVERNMENT WAY
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City | COEUR D ALENE
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State | ID
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Zip | 83815-3750
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Country | US
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Telephone | 208-771-4474
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Fax | 208-664-1001
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Authorized Official
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Title or Position | CHIROPRACTIC
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Name | RYAN SOUSLEY
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Credential | DC
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Telephone | 208-771-4474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIA1447
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License Number State | ID
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