Healthcare Provider Details

I. General information

NPI: 1417040031
Provider Name (Legal Business Name): ENERGETIC CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 N. ORCHARD STREET
BOISE ID
83706-2231
US

IV. Provider business mailing address

1003 N ORCHARD ST
BOISE ID
83706-2231
US

V. Phone/Fax

Practice location:
  • Phone: 208-376-3113
  • Fax: 208-376-4114
Mailing address:
  • Phone: 208-376-3113
  • Fax: 208-376-4114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberC392
License Number StateID

VIII. Authorized Official

Name: DR. MICHAEL MYRTH MORIARTY
Title or Position: OWNER/PRESIDENT
Credential: D.C.
Phone: 208-376-3113