Healthcare Provider Details

I. General information

NPI: 1760413256
Provider Name (Legal Business Name): EVANS CHIROPRACTIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 W BURNSIDE D
CHUBBUCK ID
83202
US

IV. Provider business mailing address

2010 FLANDRO DRIVE
POCATELLO ID
83202-1947
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-0600
  • Fax: 208-238-0603
Mailing address:
  • Phone: 208-238-0600
  • Fax: 208-238-0603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-1178
License Number StateID

VIII. Authorized Official

Name: DR. NATHAN EVANS
Title or Position: OWNER DOCTOR
Credential: DC
Phone: 208-238-0600