MEDICARE: PERFORMANCE AND REHABILITATION CHIROPRACTIC

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-1358	ID

General Provider Information

NPI Number	:	1336380450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE AND REHABILITATION CHIROPRACTIC

Provider Business Mailing Address
First Line	:	2525 N STOKESBERRY PL STE B
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-1144
Country	:	US
Telephone Number	:	208-955-6610
Fax Number	:	208-955-6612

Provider Business Practice Location Address
First Line	:	2525 N STOKESBERRY PL STE B
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-1144
Country	:	US
Telephone Number	:	208-955-6610
Fax Number	:	208-955-6612

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	DR. DENNIS RYAN GRIFFETH
Credential	:	D.C.
Telephone Number	:	208-955-6610

Provider Enumeration Date	:	03/19/2009
Last Update Date	:	06/21/2018

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