Healthcare Provider Details

I. General information

NPI: 1467877811
Provider Name (Legal Business Name): MADISON GRZESZKOWIAK D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2014
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 S JEFFERSON ST
MOSCOW ID
83843-2937
US

IV. Provider business mailing address

414 S JEFFERSON ST
MOSCOW ID
83843-2937
US

V. Phone/Fax

Practice location:
  • Phone: 208-596-1105
  • Fax: 208-883-6559
Mailing address:
  • Phone: 208-596-1105
  • Fax: 208-883-6559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA1577
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: