Healthcare Provider Details

I. General information

NPI: 1487717054
Provider Name (Legal Business Name): TY OGATA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12353 W MCMILLAN RD
BOISE ID
83713-5052
US

IV. Provider business mailing address

12353 W MCMILLAN RD
BOISE ID
83713-5052
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-3334
  • Fax: 208-938-3335
Mailing address:
  • Phone: 208-938-3334
  • Fax: 208-938-3335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA920
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: