Healthcare Provider Details

I. General information

NPI: 1528535986
Provider Name (Legal Business Name): ELEVATED CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 BOND AVE
REXBURG ID
83440-3582
US

IV. Provider business mailing address

1134 BOND AVE
REXBURG ID
83440-3582
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-8818
  • Fax: 208-356-0458
Mailing address:
  • Phone: 208-356-8818
  • Fax: 208-356-0458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. KERRY CHANT WILLIAMS
Title or Position: OWNER
Credential: DC
Phone: 208-356-8818