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General NPI Number Information
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NPI Number | 1154938983
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Entity Type | Organization
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Legal Business Name | BODY OF A CHAMPION CHIROPRACTIC, PC
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Dates
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Enumeration Date | 09/25/2020
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Last Update Date | 09/25/2020
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Provider Practice Location Address
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Address Line | 9196 W EMERALD ST STE 120
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City | BOISE
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State | ID
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Zip | 83704-8003
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Country | US
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Telephone | 208-990-7010
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Fax |
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Provider Business Mailing Address
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Address Line | 9196 W EMERALD ST STE 120
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City | BOISE
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State | ID
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Zip | 83704-8003
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Country | US
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Telephone | 208-990-7010
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. MADISON J WILLS
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Credential | DC
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Telephone | 208-990-7010
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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 |
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License Number State |
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