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General NPI Number Information
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NPI Number | 1114124138
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Entity Type | Organization
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Legal Business Name | BOISE SPORTS CHIROPRACTIC CLINIC
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Dates
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Enumeration Date | 07/02/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 3314 N COLE RD
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City | BOISE
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State | ID
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Zip | 83704-4403
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Country | US
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Telephone | 208-377-9930
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Fax |
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Provider Business Mailing Address
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Address Line | 3314 N COLE RD
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City | BOISE
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State | ID
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Zip | 83704-4403
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KEVIN HEARON
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Credential | D.C., C.C.S.P
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Telephone | 208-377-9930
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NN1001X
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Taxonomy Name | Nutrition Chiropractor
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License Number | C-4918
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | C-4918
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | C-4918
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License Number State | ID
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Taxonomy #4
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | C-4918
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License Number State | ID
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Taxonomy #5
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Taxonomy Code | 111NX0800X
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Taxonomy Name | Orthopedic Chiropractor
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License Number | C-4918
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License Number State | ID
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