MEDICARE: GRAND TETON CHIROPRACTIC, PLLC

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 904	ID

General Provider Information

NPI Number	:	1891880779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND TETON CHIROPRACTIC, PLLC

Provider Business Mailing Address
First Line	:	4317 AMBER LN
Second Line	:
City	:	AMMON
State	:	ID
Zip	:	83406-4640
Country	:	US
Telephone Number	:	208-529-1919
Fax Number	:	208-552-9447

Provider Business Practice Location Address
First Line	:	1387 CAMBRIDGE DR
Second Line	:	SUITE 100
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-4257
Country	:	US
Telephone Number	:	208-529-1919
Fax Number	:	208-552-9447

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	DR. JAMES CRIDDLE GARDNER
Credential	:	D.C.
Telephone Number	:	208-529-1919

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/22/2020

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