=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578744058
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALPINE CHIROPRACTIC CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2007
-----------------------------------------------------
Last Update Date | 11/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 296 SUNSET AVE W 15
-----------------------------------------------------
City | COEUR D'ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-667-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 296 SUNSET AVE W 15
-----------------------------------------------------
City | COEUR D'ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-667-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | KRIS ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-667-3000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | CHIA568
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------