MEDICARE: SNAKE RIVER FAMILY CHIROPRACTIC HEALTH AND WELLNESS CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHIA-1290	ID

General Provider Information

NPI Number	:	1275794968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SNAKE RIVER FAMILY CHIROPRACTIC HEALTH AND WELLNESS CENTER

Provider Business Mailing Address
First Line	:	275 N WOODRUFF AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-4303
Country	:	US
Telephone Number	:	208-528-4228
Fax Number	:	208-523-4174

Provider Business Practice Location Address
First Line	:	275 N WOODRUFF AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-4303
Country	:	US
Telephone Number	:	208-528-4228
Fax Number	:	208-523-4174

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DR. WADE KELLY PRICE
Credential	:	D.C.
Telephone Number	:	208-528-4228

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	12/01/2008

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