Healthcare Provider Details

I. General information

NPI: 1245727593
Provider Name (Legal Business Name): MARCO ANTONIO RUVALCABA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2018
Last Update Date: 11/12/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 E LOUISE AVE SUITE 110
MERIDIAN ID
83642
US

IV. Provider business mailing address

3223 E LOUISE AVE SUITE 110
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-0200
  • Fax: 208-648-4086
Mailing address:
  • Phone: 208-466-0200
  • Fax: 208-648-4086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6461971
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number34180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: