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General NPI Number Information
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NPI Number | 1891985826
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Entity Type | Organization
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Legal Business Name | BACK COUNTRY CHIROPRACTIC PLLC
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Dates
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Enumeration Date | 07/26/2007
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Last Update Date | 07/26/2007
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Provider Practice Location Address
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Address Line | 104 N BRIDGE ST SUITE 104
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City | SAINT ANTHONY
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State | ID
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Zip | 83445-1455
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Country | US
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Telephone | 208-624-2222
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Fax | 208-624-2220
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Provider Business Mailing Address
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Address Line | PO BOX 586
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City | SAINT ANTHONY
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State | ID
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Zip | 83445-0586
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Country | US
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Telephone | 208-624-2222
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Fax | 208-624-2220
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Authorized Official
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Title or Position | OWNER/ CHIROPRACTIC PHYSICIAN
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Name | DR. PAUL CLEMENT HILL
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Credential | DC
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Telephone | 208-624-2222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIA-1145
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License Number State | ID
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