=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821024134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHIROPRACTIC PAIN RELIEF CLINIC P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2006
-----------------------------------------------------
Last Update Date | 10/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8109 N WAYNE BLVD
-----------------------------------------------------
City | HAYDEN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83835-5031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-667-7463
-----------------------------------------------------
Fax | 208-762-6385
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8109 N WAYNE BLVD
-----------------------------------------------------
City | HAYDEN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83835-5031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-667-7463
-----------------------------------------------------
Fax | 208-762-6385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. RANDALL P PRIEBE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 208-667-7463
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIA-856
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------