Healthcare Provider Details

I. General information

NPI: 1336273267
Provider Name (Legal Business Name): HEALTHY HABITS WELLNESS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 S BALTIC PL
MERIDIAN ID
83642-5935
US

IV. Provider business mailing address

14 S BALTIC PL
MERIDIAN ID
83642-5935
US

V. Phone/Fax

Practice location:
  • Phone: 208-887-4872
  • Fax: 208-887-6331
Mailing address:
  • Phone: 208-887-4872
  • Fax: 208-887-6331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-1089
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. KIMBALL T LUNDAHL
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 208-887-4872