=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811173065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORBIN CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2008
-----------------------------------------------------
Last Update Date | 01/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 760 BLUE LAKES BLVD N STE 1
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-4000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-733-0411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 760 BLUE LAKES BLVD N STE 1
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-4000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-733-0411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RONALD CORBIN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 208-733-0411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIA-312
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------