=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700910726
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY TREES D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 823 CENTER AVE
-----------------------------------------------------
City | PAYETTE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83661-2535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-642-3404
-----------------------------------------------------
Fax | 208-642-9060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 354
-----------------------------------------------------
City | PAYETTE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83661-0354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-642-3404
-----------------------------------------------------
Fax | 208-642-9060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIA-7879
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------