MEDICARE: GARY CHRISTOPHER WIGHT D.C.

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	CHIA-1163	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C5612	OTHER	ID	BLUE CROSS ID#

General Provider Information

NPI Number	:	1215012554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY CHRISTOPHER WIGHT D.C.

Provider Business Mailing Address
First Line	:	333 S WOODRUFF AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-4322
Country	:	US
Telephone Number	:	208-522-2591
Fax Number	:	208-524-7489

Provider Business Practice Location Address
First Line	:	203 N HOLMES AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-2613
Country	:	US
Telephone Number	:	208-522-2591
Fax Number	:	208-522-2591

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	09/27/2021

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