=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194057802
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL D. RAE D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2010
-----------------------------------------------------
Last Update Date | 12/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1843 S BROADWAY AVE STE 203A
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-3862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-345-3630
-----------------------------------------------------
Fax | 208-345-3640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1843 S. BROADWAY AVE, SUITE 203A
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-985-3233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIA-1332
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------