Healthcare Provider Details

I. General information

NPI: 1679648679
Provider Name (Legal Business Name): JEREMY HENRY RAUSCH D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 S MAPLE GROVE RD
BOISE ID
83709-1610
US

IV. Provider business mailing address

1390 S MAPLE GROVE RD
BOISE ID
83709-1610
US

V. Phone/Fax

Practice location:
  • Phone: 208-672-0100
  • Fax: 208-672-0200
Mailing address:
  • Phone: 208-672-0100
  • Fax: 208-672-0200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA- 1169
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: