=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295921278
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. JASON B. WELKER, D.C. P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2007
-----------------------------------------------------
Last Update Date | 09/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1514 S 800 W SUITE 100
-----------------------------------------------------
City | PRESTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83263-5444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-852-2875
-----------------------------------------------------
Fax | 253-563-5264
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1514 S 800 W SUITE 100
-----------------------------------------------------
City | PRESTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83263-5444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-852-2875
-----------------------------------------------------
Fax | 253-563-5264
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JASON BLAIN WELKER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 208-852-2875
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIA-1225
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------