Provider Demographics
NPI:1053359448
Name:SACKETT, ANGELA J (DC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:J
Last Name:SACKETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1861
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1861
Mailing Address - Country:US
Mailing Address - Phone:208-528-6010
Mailing Address - Fax:208-528-6011
Practice Address - Street 1:1278 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5544
Practice Address - Country:US
Practice Address - Phone:208-528-6010
Practice Address - Fax:208-528-6011
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-861111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1675200Medicare ID - Type Unspecified
IDU94457Medicare UPIN