=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013705664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOULEVARD CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2025
-----------------------------------------------------
Last Update Date | 05/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5216 CLEVELAND BLVD STE G
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83607-8124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-899-7323
-----------------------------------------------------
Fax | 208-402-5911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5216 CLEVELAND BLVD STE G
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83607-8124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-899-7323
-----------------------------------------------------
Fax | 208-402-5911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RYAN GIB HEIN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 208-899-7323
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------