Healthcare Provider Details

I. General information

NPI: 1962542332
Provider Name (Legal Business Name): MARIA M MARICICH D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: L MARIA MARICICH D.C.

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 4TH ST. E, SUITE 310
KETCHUM ID
83340
US

IV. Provider business mailing address

PO BOX 6459
KETCHUM ID
83340
US

V. Phone/Fax

Practice location:
  • Phone: 208-726-6010
  • Fax: 208-726-6010
Mailing address:
  • Phone: 208-726-6010
  • Fax: 208-726-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberC622
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberCHIA622
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License NumberCHIA622
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License NumberCHIA622
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIA622
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: