=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760879928
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BARRY LEE OGLESBEE DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2015
-----------------------------------------------------
Last Update Date | 12/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2126 N EAGLE RD STE 120
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-6406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-391-3534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 699 E STATE ST APT H103
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-5999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-979-3669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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-1774
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------