=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720483621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREHAB HEALTH AND PERFORMANCE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2014
-----------------------------------------------------
Last Update Date | 12/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 W FRANKLIN RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-2913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-906-1564
-----------------------------------------------------
Fax | 208-906-1564
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 W FRANKLIN RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-2913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-906-1564
-----------------------------------------------------
Fax | 208-906-1564
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEVEN BAKER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 208-906-1564
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIA-1388
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------