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General NPI Number Information
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NPI Number | 1861574410
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Entity Type | Organization
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Legal Business Name | EAGLE SPORT & FAMILY CHIROPRACTIC PLLC
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Dates
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Enumeration Date | 10/20/2006
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Last Update Date | 04/03/2013
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Provider Practice Location Address
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Address Line | 547 S FITNESS PL SUITE 110
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City | EAGLE
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State | ID
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Zip | 83616-6552
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Country | US
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Telephone | 208-939-3986
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Fax | 208-319-2700
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Provider Business Mailing Address
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Address Line | 547 S FITNESS PL SUITE 110
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City | EAGLE
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State | ID
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Zip | 83616-6552
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Country | US
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Telephone | 208-939-3986
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Fax | 208-319-2700
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Authorized Official
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Title or Position | OWNER
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Name | MR. KRAIG K KNOTTS
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Credential | D. C.
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Telephone | 208-939-3986
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | CHIA-1073
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License Number State | ID
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