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General NPI Number Information
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NPI Number | 1679724330
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Entity Type | Organization
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Legal Business Name | ACTIVE CHIROPRACTIC, PC
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Dates
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Enumeration Date | 09/30/2008
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Last Update Date | 02/18/2010
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Provider Practice Location Address
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Address Line | 1521 E BOISE AVE
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City | BOISE
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State | ID
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Zip | 83706-5064
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Country | US
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Telephone | 208-345-3320
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Fax |
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Provider Business Mailing Address
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Address Line | 1521 E BOISE AVE
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City | BOISE
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State | ID
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Zip | 83706-5064
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Country | US
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Telephone | 208-345-3320
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JASON WATSON
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Credential | DC
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Telephone | 208-345-3320
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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 | CHIA-1209
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License Number State | ID
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