Healthcare Provider Details

I. General information

NPI: 1083629448
Provider Name (Legal Business Name): SUE V. PHILLIPS D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 ADDISON AVE E
TWIN FALLS ID
83301-5343
US

IV. Provider business mailing address

1625 ADDISON AVE E
TWIN FALLS ID
83301-5343
US

V. Phone/Fax

Practice location:
  • Phone: 208-735-2442
  • Fax: 208-735-9030
Mailing address:
  • Phone: 208-735-2442
  • Fax: 208-735-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberCHIA 761
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: