MEDICARE: 5 MILE PLAZA CHIROPRACTIC CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHIA4603	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	111458	OTHER	ID	UNITED HEALTHCARE
2	T44479	OTHER	ID	UPIN

General Provider Information

NPI Number	:	1053544510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	5 MILE PLAZA CHIROPRACTIC CENTER

Provider Business Mailing Address
First Line	:	10406 OVERLAND RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83709-1433
Country	:	US
Telephone Number	:	208-322-0051
Fax Number	:

Provider Business Practice Location Address
First Line	:	10406 OVERLAND RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83709-1433
Country	:	US
Telephone Number	:	208-322-0051
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SCOTT R MEISSNER
Credential	:	D.C.
Telephone Number	:	208-322-0051

Provider Enumeration Date	:	09/01/2009
Last Update Date	:	09/01/2009

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