MEDICARE: MIRANDA HOLWEGE 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-1763	ID

General Provider Information

NPI Number	:	1215462304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA HOLWEGE D.C.

Provider Business Mailing Address
First Line	:	1501 WAGON WHEEL DR APT 3
Second Line	:
City	:	BLACKFOOT
State	:	ID
Zip	:	83221-3087
Country	:	US
Telephone Number	:	801-604-7785
Fax Number	:

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	:

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

Provider Enumeration Date	:	04/26/2017
Last Update Date	:	04/26/2017

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