Healthcare Provider Details

I. General information

NPI: 1114124138
Provider Name (Legal Business Name): BOISE SPORTS CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3314 N COLE RD
BOISE ID
83704-4403
US

IV. Provider business mailing address

3314 N COLE RD
BOISE ID
83704-4403
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-9930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberC-4918
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberC-4918
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberC-4918
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberC-4918
License Number StateID
# 5
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberC-4918
License Number StateID

VIII. Authorized Official

Name: DR. KEVIN HEARON
Title or Position: OWNER
Credential: D.C., C.C.S.P
Phone: 208-377-9930