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General NPI Number Information
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NPI Number | 1093009847
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Entity Type | Organization
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Legal Business Name | JEROME CHIROPRACTIC CLINIC PLLC
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Dates
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Enumeration Date | 06/08/2011
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Last Update Date | 06/08/2011
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Provider Practice Location Address
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Address Line | 213 S LINCOLN AVE
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City | JEROME
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State | ID
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Zip | 83338-2624
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Country | US
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Telephone | 208-324-0222
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Fax | 208-324-0223
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Provider Business Mailing Address
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Address Line | PO BOX 632
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City | JEROME
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State | ID
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Zip | 83338-0632
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Country | US
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Telephone | 208-324-0222
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Fax | 208-324-0223
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK MCCLAIN SACCOMAN
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Credential | D.C.
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Telephone | 208-324-0222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | CHIA-650
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License Number State | ID
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