=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124303094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | N.E.X.T. LEVEL HEALTH CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2011
-----------------------------------------------------
Last Update Date | 12/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2105 NIAGARA
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-528-6010
-----------------------------------------------------
Fax | 208-528-6011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2105 NIAGARA ST.
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-528-6010
-----------------------------------------------------
Fax | 208-528-6011
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUSTIN TYRELL HAMMON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 208-528-6010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | ACT-251
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | CHIA-1341
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------