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General NPI Number Information
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NPI Number | 1417370511
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Entity Type | Organization
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Legal Business Name | HAYDEN LAKE CHIROPRACTIC PA
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Dates
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Enumeration Date | 01/24/2014
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Last Update Date | 01/24/2014
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Provider Practice Location Address
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Address Line | 8235 N CORNERSTONE DR
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City | HAYDEN
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State | ID
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Zip | 83835-8683
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Country | US
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Telephone | 208-762-0222
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Fax | 208-762-5362
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Provider Business Mailing Address
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Address Line | 8235 N CORNERSTONE DR
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City | HAYDEN
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State | ID
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Zip | 83835-8683
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Country | US
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Telephone | 208-762-0222
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Fax | 208-762-5362
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEVIN ROBERT MARSH
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Credential | D.C.
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Telephone | 208-762-0222
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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-699
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License Number State | ID
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