=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164889226
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT SPINE AND SPORT CHIROPRACTIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2016
-----------------------------------------------------
Last Update Date | 12/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 237 N 2ND E SUITE 106
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-4977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-881-5525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 237 N 2ND E SUITE 106
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-4977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-881-5525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ PHYSICIAN
-----------------------------------------------------
Name | DR. KIMBALL S ARRITT
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 208-881-5525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | CHIA-1705
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------