Provider Demographics
NPI:1215437751
Name:ELEVATED LIFE FAMILY CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:ELEVATED LIFE FAMILY CHIROPRACTIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:SEARLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-357-1949
Mailing Address - Street 1:120 N EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1105
Mailing Address - Country:US
Mailing Address - Phone:208-357-1949
Mailing Address - Fax:
Practice Address - Street 1:120 N EMERSON AVE
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1105
Practice Address - Country:US
Practice Address - Phone:208-357-1949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1789111N00000X, 111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Single Specialty