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General NPI Number Information
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NPI Number | 1639280712
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Entity Type | Organization
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Legal Business Name | IDAHO CHIROPRACTIC GROUP, PLLC
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 403 S 11TH ST SUITE #110
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City | BOISE
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State | ID
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Zip | 83702-6968
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Country | US
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Telephone | 208-343-6900
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Fax | 208-343-0642
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Provider Business Mailing Address
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Address Line | PO BOX 7442
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City | BOISE
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State | ID
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Zip | 83707-1442
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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 | BILLING MANAGER
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Name | JULIE CAREAGA
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Credential |
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Telephone | 208-343-6900
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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-802
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIA-559
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License Number State | ID
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