Provider Demographics
NPI:1861574410
Name:EAGLE SPORT & FAMILY CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:EAGLE SPORT & FAMILY CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KRAIG
Authorized Official - Middle Name:K
Authorized Official - Last Name:KNOTTS
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:208-939-3986
Mailing Address - Street 1:547 S FITNESS PL
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6552
Mailing Address - Country:US
Mailing Address - Phone:208-939-3986
Mailing Address - Fax:208-319-2700
Practice Address - Street 1:547 S FITNESS PL
Practice Address - Street 2:SUITE 110
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6552
Practice Address - Country:US
Practice Address - Phone:208-939-3986
Practice Address - Fax:208-319-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1073111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty