Healthcare Provider Details

I. General information

NPI: 1003930967
Provider Name (Legal Business Name): GARY D MUSGRAVE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2007
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3314 N. COLE RD.
BOISE ID
83704
US

IV. Provider business mailing address

3314 N. COLE RD.
BOISE ID
83704
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-9930
  • Fax: 208-377-9932
Mailing address:
  • Phone: 208-377-9930
  • Fax: 208-377-9932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIA-1306
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1586
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: