Healthcare Provider Details

I. General information

NPI: 1215230859
Provider Name (Legal Business Name): SCOTT MAX SERR D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2010
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 OAKLEY AVE
BURLEY ID
83318-1840
US

IV. Provider business mailing address

11 N 750 W
PAUL ID
83347-8716
US

V. Phone/Fax

Practice location:
  • Phone: 208-878-2273
  • Fax:
Mailing address:
  • Phone: 208-670-2206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-1433
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: