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General NPI Number Information
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NPI Number | 1639429541
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Entity Type | Organization
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Legal Business Name | IDEALSPINE HEALTH CENTER
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Dates
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Enumeration Date | 09/18/2012
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Last Update Date | 02/21/2013
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Provider Practice Location Address
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Address Line | 950 E RIVERSIDE DR
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City | EAGLE
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State | ID
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Zip | 83616-6020
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Country | US
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Telephone | 208-939-2502
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Fax |
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Provider Business Mailing Address
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Address Line | 950 E RIVERSIDE DR
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City | EAGLE
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State | ID
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Zip | 83616-6020
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Country | US
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Telephone | 208-939-2502
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. SHIRLENE HARRISON
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Credential | D.C.
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Telephone | 208-939-2502
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | CHIA-1168
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License Number State | ID
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