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General NPI Number Information
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NPI Number | 1316113368
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Entity Type | Organization
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Legal Business Name | UPPER CERVICAL CLINICS OF IDAHO
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Dates
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Enumeration Date | 04/30/2008
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Last Update Date | 04/30/2008
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Provider Practice Location Address
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Address Line | 3023 E COPPER POINT DR STE 104
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City | MERIDIAN
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State | ID
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Zip | 83642-1740
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Country | US
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Telephone | 208-559-0541
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Fax |
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Provider Business Mailing Address
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Address Line | 3211 CAMROSE LN
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City | BOISE
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State | ID
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Zip | 83706-2710
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | GRAYSON BLOM
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Credential | D.C.
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Telephone | 208-559-0541
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | CHIA-1297
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License Number State | ID
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