Healthcare Provider Details

I. General information

NPI: 1316117005
Provider Name (Legal Business Name): MNA GIBSON P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7A REICH ST.
MARSING ID
83639
US

IV. Provider business mailing address

3536 E TALLOW LN
BOISE ID
83716-7092
US

V. Phone/Fax

Practice location:
  • Phone: 208-896-5520
  • Fax: 208-896-9920
Mailing address:
  • Phone: 208-921-1781
  • Fax: 208-896-9920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-1130
License Number StateID

VIII. Authorized Official

Name: MR. MARK WILLIAM GIBSON
Title or Position: PRESIDENT
Credential: D.C.
Phone: 208-896-5520