Healthcare Provider Details

I. General information

NPI: 1124157664
Provider Name (Legal Business Name): WEST CHIROPRACTIC CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 CALL PLACE
POCATELLO ID
83201
US

IV. Provider business mailing address

1188 CALL PLACE
POCATELLO ID
83201
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-3216
  • Fax: 208-232-9412
Mailing address:
  • Phone: 208-232-3216
  • Fax: 208-232-9412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA1460
License Number StateID
# 5
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA940
License Number StateID

VIII. Authorized Official

Name: DR. JASON D WEST
Title or Position: OWNER
Credential: D.C., NMD
Phone: 208-232-3216