Healthcare Provider Details

I. General information

NPI: 1891909636
Provider Name (Legal Business Name): PREMIER HEALTH SYSTEMS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 W BOISE AVE
BOISE ID
83706-3503
US

IV. Provider business mailing address

1149 W BOISE AVE
BOISE ID
83706-3503
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-3630
  • Fax: 208-345-3640
Mailing address:
  • Phone: 208-345-3630
  • Fax: 208-345-3640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA1046
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number895294
License Number StateID

VIII. Authorized Official

Name: DR. BRIAN J RAE
Title or Position: DOCTOR, OWNER
Credential: D.C.
Phone: 208-345-3630