MEDICARE: EASTERN IDAHO CHIROPRACTIC CLINIC PA

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		ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000010020547	OTHER	ID	BLUE SHIELD INSURANCE
2	C9453	OTHER	ID	BLUE CROSS INSURANCE

General Provider Information

NPI Number	:	1588732523
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERN IDAHO CHIROPRACTIC CLINIC PA

Provider Business Mailing Address
First Line	:	2585 CHANNING WAY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7516
Country	:	US
Telephone Number	:	208-522-0200
Fax Number	:	208-523-6051

Provider Business Practice Location Address
First Line	:	2585 CHANNING WAY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7516
Country	:	US
Telephone Number	:	208-522-0200
Fax Number	:	208-523-6051

Authorized Official
Title or Position	:	CHIROPRACTIC NATUROPATHIC MEDICAL
Name	:	DR. LARRY DEAN NELSON
Credential	:	D.C.N.M.D
Telephone Number	:	208-522-0200

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	12/18/2015

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Directions to “EASTERN IDAHO CHIROPRACTIC CLINIC PA ” Practice Location

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