Healthcare Provider Details

I. General information

NPI: 1669387114
Provider Name (Legal Business Name): PINE RIDGE CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31911 N 5TH AVE
SPIRIT LAKE ID
83869
US

IV. Provider business mailing address

PO BOX 1702
SPIRIT LAKE ID
83869-1606
US

V. Phone/Fax

Practice location:
  • Phone: 208-255-0031
  • Fax:
Mailing address:
  • Phone: 208-255-0031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ALLI STOCKTON
Title or Position: SECRETARY
Credential:
Phone: 208-255-0031