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General NPI Number Information
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NPI Number | 1063903359
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Entity Type | Organization
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Legal Business Name | THE CHIROPRACTOR AT CASTLEBURY
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Dates
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Enumeration Date | 05/23/2018
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Last Update Date | 05/23/2018
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Provider Practice Location Address
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Address Line | 3225 W BAVARIA ST STE 101
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City | EAGLE
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State | ID
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Zip | 83616-5547
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Country | US
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Telephone | 208-884-8848
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Fax | 208-884-8802
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Provider Business Mailing Address
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Address Line | 3225 W BAVARIA ST STE 101
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City | EAGLE
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State | ID
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Zip | 83616-5547
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Country | US
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Telephone | 208-884-8848
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Fax | 208-884-8802
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Authorized Official
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Title or Position | MEMBER
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Name | DR. GARY CRAIG ELLISON
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Credential | DC
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Telephone | 208-884-8848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIA-845
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License Number State | ID
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