MEDICARE: BOISE VALLEY CHIROPRACTIC LLC

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-1060	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000010155358	OTHER	ID	REGENCE BLUE SHEILD OF ID
2	C5619	OTHER	ID	BLUE CROSS OF IDAHO ID

General Provider Information

NPI Number	:	1811062714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOISE VALLEY CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	1740 N. MILWAUKEE ST.
Second Line	:	SUITE B
City	:	BOISE
State	:	ID
Zip	:	83704
Country	:	US
Telephone Number	:	208-377-9500
Fax Number	:	208-377-8449

Provider Business Practice Location Address
First Line	:	1740 N. MILWAUKEE ST.
Second Line	:	SUITE B
City	:	BOISE
State	:	ID
Zip	:	83704
Country	:	US
Telephone Number	:	208-377-9500
Fax Number	:	208-377-8449

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. JAMES H BINGHAM
Credential	:	D.C.
Telephone Number	:	208-377-9500

Provider Enumeration Date	:	11/24/2006
Last Update Date	:	08/22/2020

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Directions to “BOISE VALLEY CHIROPRACTIC LLC ” Practice Location

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