Healthcare Provider Details

I. General information

NPI: 1164167904
Provider Name (Legal Business Name): FRUITLAND CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 N WHITLEY DR
FRUITLAND ID
83619-2132
US

IV. Provider business mailing address

2007 N WHITLEY DR
FRUITLAND ID
83619-2132
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-4455
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. TAYLOR MAHLER
Title or Position: OWNER
Credential: DC
Phone: 208-452-4455