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General NPI Number Information
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NPI Number | 1215285739
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Entity Type | Organization
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Legal Business Name | MERIDIAN CHIROPRACTIC CLINIC LLC
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Dates
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Enumeration Date | 08/15/2012
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Last Update Date | 01/09/2013
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Provider Practice Location Address
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Address Line | 323 W PINE AVE
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City | MERIDIAN
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State | ID
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Zip | 83642-2238
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Country | US
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Telephone | 208-888-5858
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Fax |
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Provider Business Mailing Address
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Address Line | 323 W PINE AVE
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City | MERIDIAN
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State | ID
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Zip | 83642-2238
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Country | US
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Telephone | 208-220-3666
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Fax |
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Authorized Official
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Title or Position | OWNER/CHIROPRACTOR
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Name | DR. DAVID V JESSOP JR.
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Credential | D.C.
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Telephone | 208-888-5858
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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 | CHIA-1514
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License Number State | ID
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