=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942982822
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIAN CREEK CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2023
-----------------------------------------------------
Last Update Date | 08/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2523 S 10TH AVE STE 102
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83605-6760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-649-4321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2523 S 10TH AVE STE 102
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83605-6760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-649-4321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. JORDAN WEAVER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 208-949-5347
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------